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[JURIES  TO  THE  EYE 


IN  THEIR 


iEDico-LEGAL  Aspect 


S.Baudry.  M.D. 


1 


./ 


m 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


.^^M 


GIN  BROS. 

DJCAL  BOOKS 
HARRISON  ST.  CHICAGO 


INJURIES  TO  THE  EYE 


IN  THEIR 


MEDICO-LEGAL  ASPECT 


S.  BAUDRY,  M.D. 

Professor  js  the  Facultv  of  Medicine,  University  of  Lille.  France,  etc. 


Translated  from  the  Original  by 
ALFRED  JAMES  OSTHEIMER,  Jk.,  M.D. 

OF  Philadelphia,  Pa. 

Revised  and  Edited  by 
CHARLES  A.  OLIVER,  A.M.,  M.D. 

Attending  Surueon  to  the  AVills  Eve  Hospital.  Ophthalmic  Surgeon  to  the  Philadelphia 
Hospital;   Member  of  the  American  and  French  Ophthalmological  Societies,  etc. 

With  an  Adaptation  of  the  Medico-legal  Chapter  to  the  Courts 
OF  THE  United  States  of  Ajierica  by 

CHARLES  SINKLER,  Esq. 

Member    of    the    Philadelphia    Bar 


Philadelphia,  New  York,  Chicago 
THE  F.  A.  DAVIS  COMPANY,  PUBLISHERS 

1900 


COPYRIGHT,  1900, 

BY 

THE  F.  A.  DAVIS  COMPANY. 


[Registered  at  Stationers'  Hall.  Lonami,  Eng. 


Philadelpliia,  Pa..  U.  S.  A. 

Ttie  Medical  BuUetiu  Printing-house, 

1914-16  Cherry  Street. 


TO 


HAMPTON  L.  CARSON,  A.M.,  LL.D., 

Professor  of  Law  in  the  University  of 
Pennsylvania, 


THIS 


English  Edition  of  Professor  Baudry's  Work 


IS 


RESPECTFULLY  DEDICATED 


BY   THE 


American  Editor. 


^. 


ontro 
AAl 


AUTHOE"S  PKEFACE. 


TitAU-MATic  lesions  of  the  eye  and  ol'  the  adnexu  uceiii 
most  frequently  in  industrial  localities,  where,  for  instance, 
metal  factories,  machine-shops,  quarries,  and  mines  pre- 
dominate. Almost  daily  this  type  of  cases  comes  to  the 
physician;  and,  since  many  such  injuries  produce  dimness 
of  vision  or  give  rise  to  complete  hlindness,  and  thereby, 
at  times,  become  the  canse  of  suits  for  damages,  lie  is  often 
called  upon  to  state,  in  a  medico-legal  way,  tlie  cause,  the 
nature,  and  the  consequences  of  such  traumatisms. 

In  certain  cases  the  eye  may  be  the  seat  of  congenital 
anomalies,  or  it  may  exhibit  more  or  less  serious  acquired 
lesions  that  have  antedated  the  alleged  accidental  cause  of 
the  condition,  and  this,  perhaps,  unknown  to  the  patient; 
so  Hint,  i\\  limes,  it  1)econi('S  necessary  to  dilTci-enliate 
whether  a  luss  of  vision,  wliieli  may  lie  |i;nii;il  oi-  eoiii|ile|e, 
is  due  lo  sonu!  definite  injury  or  wliellier  il  is  (le|ieii(leMl 
upon  some  previous  patJiologiea!  change. 

Laborers  with  a  traumatic  lesion  of  the  eye  often  pur- 
posely neglect  to  follow  a  prescril)ed  form  of  treatment; 
they  may  exaggerate  the  consequences  of  an  accident;  and 
frequently  they  may  be  induced  to  simulate  blindness,  in 
the  hope  of  obtaining  the  largest  redress  that  is  possible 
under  such  circumstances. 

As  the  answer  to  these  different  questions  so  frequently 
offers  difficulties,  and  requires  of  the  legal  ex[)ert  a  pro- 
found knowledge  of  both  the  internal  and  the  external 
diseases  of  the  visual  apparatus,  it  becomes  obligatory  that 
he  be  made  fullv  aware  of  their  medical  significance,  this 

(V) 


YJ  A  iilliur's  Pirfacc. 

being  further  emphasized  Ij}'  tlie  lact  that  it  frequeutly 
becomes  necessary,  during  the  hearing  of  suits  for  this  class 
of  injuries,  for  the  Court  to  call  for  the  testimony  of  a 
specialist  on  diseases  of  the  eye. 

Even  at  a  moment's  notice  the  expert  may  be  asked 
for  his  opinion  by  a  corporation  or  by  an  individual  re- 
garding the  gravity  of  an  injured  eye,  or  to  give  answer  as 
to  the  visual  function  of  persons  whose  interest  induces 
them  to  assert  that  they  cannot  see,  or  that  they  do  not 
see  suificiently  well  to  pursue  their  occupations. 

To  guide  the  expert,  and  to  make  it  easier  to  estimate 
accurately  the  damage  caused  l)y  the  injury  to  the  indi- 
vidual, the  author  has  attemj^ted  to  present  in  tliis  mono- 
graph a  concise  accoimt  of  the  traumatic  lesions  of  the  eye 
and  of  its  adnexa,  treating  them  especially  from  a  prog- 
]iostic  stand-point.  He  has  taken  this  opportunity  to  col- 
lect his  personal  observations, — the  larger  part  of  which 
has  not  been  published, — as  well  as  to  compile  the  reports 
and  ]niblishcd  conclusions  of  liis  predecessors  and  co- 
laborers. 

As  it  is  important  that  the  medical  expert,  after  hav- 
ing made  a  diagnosis,  should  not  commit  any  legal  error, 
a  >taicinent  of  the  mode  of  ])rocedure  to  be  pursued  in  a 
nK'dico-lcgal  examiualiou  has  been  given  in  the  final  chap- 
ter of  the  hook.  'J'he  legal  poiiion  of  this  chapter  has  been 
wriiten  by  Professor  Ja'Cqnijy,  of  Lille,  to  whom  ibe  thanks 
of  Ibe  author  are  due. 

S.  Baudry, 

Lille,  Franck. 


AMERICAN  EDITOB"S  PKEFACE. 


This  work,  which  has  achieved  such  a  reputation  iu 
I" ranee  as  to  demand  a  second  edition,  was  sent  to  the 
editor  by  the  author  with  the  statement  that,  should  the 
contribution  be  deemed  sufficiently  interesting  and  useful, 
a  translation  would  be  permitted.  Careful  reading  of  the 
original  by  the  editor  proved  the  Avork  to  be  of  so  much 
value  that  he  determined  to  accept  the  task  and  to  present 
all  English  adaptation  to  the  medical  profession. 

The  at  many  times  trying  and  ditficult  labor  of  obtain- 
ing the  first  and  literal  translation  was  assumed,  and  has 
Ix'on  conscientiously  accomplished,  by  Dr.  Alfred  J.  Os- 
theimer,  whose  name  appears  npon  the  title-page.  The 
modification  of  the  legal  side  of  the  subject  that  had  be- 
come necessary  in  order  to  accord  this  portion  of  the  work 
witli  the  American  methods  of  dealing  with  such  matters 
of  jurisprudence  has  been  accepted,  and  has  been  most 
judiciously  done,  by  ]\I]-.  Charles  Sinklcr,  to  whom  credit 
iias  also  been  given  upon  the  title-page  of  the  volume. 

The  revisional  aiul  editorial  duties — consisting  of  a 
word-to-word  comparison  of  the  translation  with  the  orig- 
in;il  text;  the  arrangement  of  the  new  matter  into  readable 
J^nglish,  with  the  preservation  of  the  author's  style  as  mncli 
as  possible;  the  preparation  of  the  revised  manuscript,  the 
verification  of  the  references,  and  the  personal  supervision  | 
of  all  of  the  press-work — have  not  been  few,  nor,  as  the 
editor  hopes,  in  vain. 

(vii) 


yjjj  AiHcricdii    IJ<HI<n's    I'rcface. 

To  Drs.  Wilbur  AV.  Bulette,  of  Pueljlo,  Colorado;  iu'ed- 
oiic'k  C.  Herrick,  of  Clevelaud,  Ohio;  Mary  E.  Gillespie  and 
>]dvvard  A.  Sliumway,  of  this  city,  many  thanks  are  due 
for  assistance  given  during  the  preparation  of  the  English 
mannscript  copy. 

Charles  A.  Oltveu. 

PlIILAUELPlIIA,   Pa. 


CONTENTS. 

PAKT  FIPvST. 
TeauiMatic  Lesions  of  the  Ocular  Adnk.va. 

CHAPTER  I. 
Eyebrows,  Eyelids,  and  Conjunctiva 1 

CHAPTER  II. 
Orbit  and  its  Contents 19 

PART  SECOND. 

Traumatic  Lesions  of  the  Eyeballs. 

CHAPTER  I. 
Cornea •^•'5 

CHAPTER  TI. 
Sclera    40 

CHAPTER  III. 
Iris    !>(» 

CHAPTER  IV. 
Choroid  and  Ciliary-  Body' 61 

CHAPTER  V. 

Retina   OS 

(ix) 


X  Contents. 

CHAPTER  VI. 
Ceystalline  Lens 77 

CHAPTER  VTl. 
Vitreous  Humor 89 

CHAPTER  VIII. 

Traumatic  Lesions  oi*'  the  Eye  as  a  Whole 97 


PART  THIRD. 

CHAPTER  I. 
Simulated  or  Exaggerated  Affections  of  the  Eye 110 


PART  FOURTH. 
Medico-legal,  Expert  Testimony 133 

Bibliography    142 

Index    151 


PAET  FIRST. 

TRAUMATIC  LESIONS  OF  THE  OCULAR 
ADNEXA. 


CHAPTER  I. 
Eyebrows,  Eyelids,  and  Conjunctiva. 

(a)  eyebrows. 

The  superciliary  region,  supported  by  the  projection 
of  the  superciliary  arch  of  the  frontal  hone,  is  exposed  to 
such  injuries  as  wounds,  burns,  and  contusions.  These 
injuries,  when  superficial  and  limited  to  the  soft  parts, 
are  not,  as  a  rule,  serious,  but  may  be  followed  by  dis- 
astrous consequences,  and  even  by  fatal  results  should 
they  affect  or  extend  to  the  underlying  bones.  Simple 
contusion  of  the  eyebrow  does  not  usually  give  rise  to 
more  than  an  ecchymotic  swelling,  resolution  of  which  is 
quickly  obtained  by  compression  and  massage.  If,  how- 
ever, a  violent  contusion  disturbs  the  soft  parts,  or  a  com- 
pound fracture  be  produced,  suppuration,  followed  by 
periostitis,  necrosis,  fistulas,  and  other  complications,  may 
take  place. 

Happily,  by  the  aid  of  asepsis  and  antisepsis,  wounds 
caused  by  cutting  implements  or  stabbing  instruments  heal 
in  a  few  days'  time,  even  if  the  injury  be  extensive  and  the 
periosteum  be  penetrated  and  exfoliated. 

(1) 


2  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

In  the  following  case  primary  union  was  obtained  and 

the  patient  resumed  work  on  the  twelfth  day  after  the 

accident,  notwithstanding  that  almost  four  centimeters  of 

the  frontal  bone  were  denuded. 

Case  I  (personal  and  previously  unpublished). — Extensive 
wound  of  the  right  superciliary  region  caused  by  the  bursting  of 
a  siphon  of  Seltzer  water.  Denudation  of  the  frontal  bone.  Re- 
union by  first  intention. 

A.  D.,  aged  34  years,  employed  in  the  manufacture  of  Seltzer 
water,  began  work  on  the  twenty-fourth  day  of  June,  1889,  with- 
out any  protecting  metal  mask.  By  the  bursting  of  a  siphon  he 
was  struck  in  the  right  superciliary  region  with  a  piece  of  glass, 
a  wound  four  centimeters  in  length  which  passed  through  the 
entire  thickness  of  the  brow  being  produced.  The  periosteum  was 
smoothly  cut  and  the  frontal  bone  was  denuded  almost  throughout 
its  entire  lengtli.  After  arresting  the  hemorrhage,  and  being  as- 
sured that  there  were  no  pieces  of  glass  in  the  wound,  three  sutures 
were  put  in  place  and  a  compress-bandage  was  applied.  Union  by 
first  intention  was  obtained,  and  the  patient  resumed  his  occupa- 
tion on  the  twelfth  day. 

In  a  wound  that  is  limited  to  the  integument  of  the 
brow  tbe  edges  have  no  tendency  to  separate,  because  of 
the  close  attachment  of  the  skin  to  the  deeper  layers  in 
this  region.  In  consequence,  there  is  no  necessity  for 
suturing,  small  bands  of  adhesive  plaster  being  sufficient" 
to  obtain  exact  coaptation. 

Reservation  as  to  prognosis  must  be  made,  however, 
if  the  wound  cannot  be  made  aseptic  by  the  removal  of 
the  foreign  bodies.  Persistent  neuralgia,  motor  and  visual 
disturbances,  and  trophic  lesions  must,  at  times,  be  ex- 
pected, if  the  supraorbital  nerve  or  any  of  its  branches 
is  wounded  or  is  imprisoned  in  an  adherent  cicatrix. 

In  the  case  of  contused  wounds  it  is  well  to  remem- 
ber that  it  is  sometimes  difficult  to  determine  the  kind 
of  instrument  by  which  they  have  been  produced,  because 


Traumatic  Lesions  of  the  Ocular  Adnexa.  3 

of  the  fact  that  some  of  these  solutions  of  continuity  of 
tissue  so  closely  resemble  wounds  that  are  caused  by  cut- 
ting instruments:  for  example,  the  sharp  edge  of  the  super- 
ciliary arch  may  cut  the  soft  parts  lying  between  the  bone 
and  the  contusing  body  from  within  outward.  Such  in- 
juries may  also  be  produced  by  falls  upon  the  ground  or 
upon  ice. 

The  diagnosis  of  this  class  of  injuries  is,  from  a  med- 
ico-legal stand-point,  of  the  greatest  iiuportance,  and  the 
prognosis  is  always  unfavorable,  not  only  on  account  of 
the  depth  of  the  wound  and  the  denudation  of  the  bone, 
but  also  by  reason  of  the  disturbance  of  the  surrounding 
tissues,  which  is  proportionate  to  the  violence  of  the  trau- 
matism. 

With  antiseptic  treatment  the  majority  of  contused 
wounds  heal  in  a  few  weeks'  time,  but  when  infection  has 
been  produced  by  the  penetration  of  a  septic  foreign  body, 
erysipelas  may  appear,  or  suppurative  inflammation  in- 
volving the  loose  cellular  tissue  of  the  upper  lid,  and  ex- 
ceptionally that  of  the  orbital  cavity  may  take  place. 

Suppuration  of  the  orbital  connective  tissue  is  in  all 
cases  a  serious  complication  of  contusions  of  the  super- 
ciliary region,  Avhile  phlegmonous  inflammation  of  the 
upper  lid  may  sometimes  lead  to  a  more  or  less  extensive 
destruction  of  tissue,  with  disfiguring  cicatrization. 

If  bone-tissue  is  involved,  osteitis,  necrosis,  and  fistulas 
may  result,  or  even  a  fatal  issue  may  ensue,  particularly 
if  the  walls  of  the  frontal  sinuses  are  fractured.  The 
prognosis  is  less  serious  when  the  lesion  is  limited  to  the 
external  wall  of  the  orbit,  as  shown  by  the  following  ob- 
servation of  Tillaux^: — 

A  girl,  aged  20  years,  with  well-developed  frontal  protuber- 
ances, fell  while  carrying  a  sandstone  pitcher,  which   broke   and 


4  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

cut  a  gaping  wound  in  the  right  brow  that  was  sufficiently  large 
easily  to  admit  a  finger.  The  base  of  the  fractured  anterior  wall 
of  the  frontal  sinus  was  forced  in,  and  a  fragment  of  the  jug 
was  imprisoned  in  the  cavity.  The  fracture  was  filled  with  blood 
and  there  was  a  pulsation  which  was  synchronous  with  the  radial 
pulse,  leading  the  observer  to  the  belief  that  the  brain-substance 
was  exposed.  A  rapid  recovery  followed  the  extraction  of  the 
foreign  body. 

Hippocrates  observed  that  injuries  of  the  brow  often 
caused  blindness,  and  surgeons  generally  endeavor  to  as- 
sociate partial  or  total  loss  of  vision,  which  may  be  tran- 
sient or  permanent,  with  contused  wounds  of  the  edge 
of  the  superciliary  region  of  the  orbit. 

Published  observations  show  that  sometimes  com- 
plete blindness  has  been  immediately  produced.  In  other 
instances  the  blindness  has  been  gradual  in  its  onset.  The 
author  has  seen  cases  of  less  pronounced  visual  disturbances 
which  have  grown  better  and  in  which  the  S3-mptoms  have 
finally  disappeared. 

Before  the  discovery  of  the  ophthalmoscope,  the 
theory  given  was  that  traumatic  irritation  usually  started 
from  the  injured  branches  and  in  various  ways  reached 
the  optic  nerve,  producing  a  sympathetic  or  a  reflex 
amaurosis.  The  experimental  and  therapeutic  sectioning 
of  the  supra-orbital  nerve,  the  existence  of  amblyopia  or 
amaurosis  produced  by  wounds  in  the  orbit, — other  than 
those  which  are  in  direct  communication  with  the  frontal 
nerve, — should  all  long  ago  have  discredited  this  idea, 
notwithstanding  the  success  of  Beer  in  performing  supra- 
orbital neurotomy.^ 

Since  the  use  of  the  ophthalmoscope  and  the  greater 
opportunity  of  making  autopsies,  anatomical  lesions  which 
have  shown  more  precise  connection  with  the  various 
forms  of  visual  disturbance  have  been  discovered.     For 


Traumatic  Lesions  of  the  Ocular  Adnexa.  5 

example,  a  retrobulbar  neuritis  following  either  a  direct 
or  an  indirect  fracture  of  the  optic  canal  (with  a  crushing 
of  the  optic  nerve  by  a  splinter  of  bone,  for  instance);  or 
a  primary  compression  of  the  nerve  by  an  extracapsular 
or  an  intracapsular  effusion  (von  Holder)  may  take  place 
from  the  same  cause;  or  a  secondary  form  of  compression 
from  callosities  or  periostitis  may  be  the  result;  again, 
intraocular  lesions,  such  as-  hemorrhages,  retinal  detach- 
ment, and  ruj)ture  of  the  choroid  may  occur. 

Moreover,  effusions  into  the  vitreous  humor,  neuritis 
produced  by  erysipelas  of  a  wound  (H.  D.  Xoyes),  or 
atrophy  from  intracranial  lesions  may  appear.  Finally,  in 
some  cases  in  which  visual  defects  are  temporary  and  are 
of  less  importance,  it  may  be  admitted,  in  the  absence  of 
absolute  anatomical  proof,  that  there  has  been  a  disturb- 
ance of  the  retina  or  of  the  nervous  centers. 

Callan^  has  reported  nine  cases  of  traumatism  ending 
in  monocular  blindness,  produced  by  fracture  of  the  orbital 
bones  at  the  optic  foramen. 

Raymond*  has  seen  a  case  of  injury  to  the  orbital 
margin  producing  a  tear  of  the  choroid,  which  had  six 
times  the  diameter  of  the  optic-nerve  head.  In  this  instance 
vision  was  abolished  for  a  long  period  of  time,  and  the  eye 
was  the  seat  of  an  intense  ciliarv  neuralgia. 

Considering  the  reports  of  all  such  cases,  there  is  but 
little  to  support  the  theory  of  a  reflex  amaurosis  that  is 
solely  connected  with  injury  to  one  of  the  branches  of  the 
frontal  nerve. 

In  1877  Badal  reported  a  case  in  which  he  extracted 
a  piece  of  wood  that  three  weeks  previously  had  pene- 
trated deeply  beneath  the  skin  above  the  brow,  and  had 
lodged  across  the  supraorbital  nerve.  The  irritation  of 
the  foreign  body  produced  a  neuroretinitis,  with  a  conse- 


6  Injuries  to  the  Eye  in  their  Medico-leyal  Aspect. 

quent  diminution  of  vision  to  one-half  of  normal.  Eapid 
recovery  followed  the  operation. 

If,  however,  it  is  decided  to  consider  an  exceptional 
form  of  reflex  amaurosis  following  lesions  of  the  fifth  pair 
as  dependent  in  great  measure  upon  traumatic  hysteria,  it 
is  not  singular  that  continuous  irritation  of  the  nerve- 
branches  that  are  imprisoned  in  a  cicatrix  which  is  ad- 
hering to  the  bone,  and  is  dragged  by  cicatricial  retraction, 
should  reappear  in  the  form  of  hyperemia,  photophobia, 
paresis  of  the  power  of  accommodation,  and  blepharo- 
spasm. De  Wecker,  indeed,  seems  to  admit  that  much 
prolonged  irritation  may  so  modify  the  intraocular  secre- 
tions as  to  produce  simple  chronic  glaucoma.^ 

The  liberation  of  the  adherent  cicatrix  and  of  the 
nerve  that  is  contained  in  the  cicatricial  tissue  is  usually 
successful  in  dissipating  the  neuralgia,  the  blepharospasm, 
and  the  visual  disturbances.  A  number  of  cases  that  are 
analogous  to  the  following  have  been  published  by  different 
surgeons. 

Case  II  (personal  and  unpublished). — Contused  wound  of 
the  left  brow.  Cicatrix  adherent  to  the  frontal  bone.  Neuralgia 
and  visual  disturbances.     Liberation  of  the  cicatrix.     Kecovery. 

G.  S.,  21  years  old,  an  apprenticed  roof-builder,  on  the  four- 
teenth of  ]\Iarch,  1890,  fell  from  the  first  stcny  of  a  building.  He 
was  picked  up  unconscious,  and  remained  in  tliis  condition  for 
several  hours'  time.  The  attending  physician  found  a  simple  fract- 
ure of  the  left  clavicle,  and  a  contused  -wound  of  the  brow  of  the 
same  side.  According  to  tlie  patient's  account,  the  wound  sup- 
purated for  twenty-five  days,  and  the  left  eye  was  closed  for 
about  fifteen  days  by  the  inflamed  and  swelled  upper  eyelid.  At 
this  time  the  patient  said  that  there  was  no  change  in  his  sight. 
He  resumed  work  a  month  after  the  accident. 

On  the  eleventh  of  July  he  consulted  tlie  author  on  account 
of  a  disturbance  of  vision  in  the  left  eye,  which  had  lasted  for 
about  six  weeks'  time.     He  complained  especially  of  photophobia 


Trantuatic  Lesions  of  the  Ocular  Adiiexa.  7 

and  of  rapid  fatigue  of  vision.  Persistent  pain,  with  exacerbations 
in  the  left  frontal  region,  was  a  prominent  symptom.  The  pain 
seemed  to  originate  in  the  wound  in  the  brow,  and  to  radiate 
toward  the  left  side  of  the  head.  The  left  eye  frequently  became 
inflamed.  At  this  visit  the  patient  asked  for  a  certificate  in  order 
to  be  able  to  claim  damages  from   an  insurance  company. 

On  a  plane  with,  and  a  little  above,  the  left  supraorbital 
notch  there  was  a  cicatrix,  wliich  was  adherent  to  the  frontal 
bone.  Slight  pressure  upon  this  region  provoked  a  localized  in- 
crease of  pain.  There  was  a  slight  contraction  of  the  muscles  that 
were  supj^lied  by  the  facial  nerve,  this  being  more  particularly 
pronounced  in  the  region  of  the  left  orbicularis.  The  external 
ocular  membranes  seemed  normal,  the  left  conjunctiva  being  but 
slightly  more  injected  than  that  of  the  right  eye.  The  left  pupil 
was  contracted.  The  refracting  media  were  transparent,  and  there 
were  no  appreciable  lesions  of  the  eyegrounds.  With  the  aid  of 
a  convex  spherical  lens  of  one  and  a  half  diopters'  strength,  the 
visual  acuity  on  each  side  became  normal.  The  visual  fields  were 
unimpaired. 

Considering  that  the  symptoms  were  due  to  an  incarceration 
of  the  nerve-filaments  in  the  cicatrix,  the  author  loosened  all  of 
the  adhesions  which  bound  the  cicatrix  to  the  underlying  bone  by 
means  of  a  tenotome,  resulting  in  the  cure  of  the  case." 

It  has  already  been  noted  that  motor  and  trophic 
disturbances  result  from  injuries  to  the  branches  of  the 
fifth  cranial  nerve.  These  cases,  however,  are  rare.  Tardif 
reports  an  example  from  de  Wecker's  clinic,  in  which  per- 
sistent contracture  and  neuralgia,  which  were  dependent 
on  the  presence  of  a  small  piece  of  wood  in  a  wound  of 
the  eyebrow,  were  permanently  relieved  by  the  extraction 
of  the  foreign  body. 

In  nervous  patients  wounds  of  the  supraorbital  nerve 
may  produce  facial  paralysis,  trismus,  and,  exceptionally, 
tetanus,  epileptic  attacks,  and  general  convulsions.'^  Ulti- 
mately such  traumatism  may  lead  to  trophic  disturbances 
of  the  face,  such  as  partial  bemiatrophy  (see  Case  IV  in 


8  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

Tardifs  thesis),  and  to  alterations  in  the  nutrition  of  the 
eye.  Briere  has  published  an  example  of  trophic  keratitis 
that  was  due  to  a  contused  wound  of  the  outer  third  of 
the  eyebrow,  and  in  which  there  was  no  direct  involve- 
ment of  the  eye.^  The  condition  known  as  enophthalmos 
has  been  reported."  In  some  cases  this  symptom  was  ac- 
companied with  a  marked  loss  of  visual  acuity. 

Wounds  caused  by  projectiles  are  to  be  placed  in  the 
same  category  as  contused  ones.  In  such  cases  the  frontal 
sinuses  may  be  opened  and  both  walls  either  splintered  or 
simply  fractured.  Injuries  that  are  limited  to  the  outer 
wall  are  rarely  serious,  the  emph3^sema  soon  disappearing, 
though  they  may  produce  a  fistula  or  act  as  a  cause  of 
delay  in  recovery.  On  the  other  hand,  if  the  cranial  wall 
is  involved,  the  prognosis  is  grave  on  account  of  the  pos- 
sible infection  of  the  meninges,  particularly  if  the  project- 
ile remains  in  the  cranial  cavity  or  if  it  becomes  imbedded 
in  the  posterior  wall  of  the  sinus. 

Burns  of  the  eyebrow  require,  for  their  healing,  a 
period  of  time  that  is  proportionate  to  the  severity  of  the 
injury.  They  always  leave  a  more  or  less  noticeable  cica- 
tricial deformity. 

From  a  medico-legal  point  of  view,  the  preceding  con- 
siderations may  be  summed  up  as  follows:  Violent  contu- 
sions and  contused  wounds  of  the  eyebrow  are  often  fol- 
lowed by  a  temporary  or  a  permanent  loss  of  vision,  which 
may  be  immediate  or  secondary.  This  diminution  of  visual 
acuity  may  depend  upon  definite  anatomical  lesions  of  the 
orbital  walls,  of  the  eyeball,  of  the  nervous  centers,  etc.; 
but  there  are,  however,  a  certain  number  of  cases  in  which 
the  ophthalmoscope  fails  to  reveal  any  alteration  of  the 
fundus  for  some  time  following  the  traumatism.  Before 
forming  an  opinion,  the  medical  expert  should,  therefore. 


Traumatic  Lesions  of  the  Ocular  Adnexa.  9 

insist  upon  having  the  patient  nncler  observation  for  sev- 
eral months'  time:  until  all  possible  retrobulbar  lesions 
have  had  sufficient  time  to  act  upon  the  nutrition  of  the 
optic  nerve. 

Keflex  amblyopia  without  material  evidence  following 
blows  upon  the  forehead,  or  insignificant  periorbital  con- 
tused wounds,  may  form  the  basis  for  damage-suits,  and 
should  be  admitted  only  with  the  greatest  reserve.  The 
expert  must  always  suspect  traumatic  hysteria,  the  diag- 
nosis often  being  of  the  utmost  importance.  Intermittent 
unilateral  amblyopia — characterized  by  a  variability  of  the 
ocular  symptoms,  absence  of  ophthalmoscopic  changes, 
and  a  concentric  contraction  of  the  visual  field  for  white 
and  for  colors — in  an  hereditary  neuropath  is  quite  pathog- 
nomonic of  traumatic  hysteria. 

Moreover,  there  are  instances  in  which  preservation 
of  the  iris-reflex  with  other  signs  suggests  an  attempt  at 
simulation;    these  will  be  considered  in  a  special  chapter. 

Injury  of  the  supraorbital  nerve  may  produce  cranio- 
facial neuralgia,  muscular  twitchings  in  the  facial  region, 
trophic  changes  in  the  eye,  and,  finally,  give  rise  to  visual 
disturbances  that  are  characterized  particularly  by  photo- 
phobia and  accommodative  asthenopia.  These  symptoms 
are  generally  curable,  and  give  but  slight  inconvenience  to 
the  patient. 

The  majority  of  wounds  caused  by  stabbing,  cutting, 
or  contusing  instruments,  and  uncomplicated  burns  that 
are  limited  to  the  soft  parts  of  the  brow,  heal  quite  rapidly, 
entailing  biit  a  brief  absence  from  work.  Fractures  of  the 
supraorbital  ridge  and  deep  wounds  of  the  frontal  sinus 
are  much  more  serious,  being  sometimes  followed  by  men- 
ingitis or  meningo-encephalitis. 

Finally   it   must  be  again   mentioned   that   contused 


10  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

wounds  of  the  brow  produced  from  within  outward  by  the 
action  of  blunt  implements,  or  by  falls,  may  present  the  ap- 
pearance of  injuries  that  have  been  caused  by  cutting  in- 
struments. From  a  medico-legal  stand-point,  it  is  impor- 
tant for  the  expert  to  recognize  this  peculiarity,  because, 
in  certain  cases,  the  accused  may  be  prosecuted  for  armed 
assault,  when  in  reality  the  wound  that  has  been  inflicted 
has  been  the  result  of  a  blow  by  a  fist. 

(b)  eyelids.^" 

Wounds  of  the  eyelids  are  quite  common,  their  grav- 
ity being  greatly  increased  when  the  lids  are  perforated 
and  when  the  eyeball  or  the  orljit  is  involved.  They  are 
commonly  due  to  blows  made  by  the  naked  or  the  armed 
fist,  to  falls  upon  resisting  surfaces,  etc.  Burns  may  result 
from  explosions  of  gas  or  of  powder,  from  the  action  of 
boiling  fiuids,  or  of  incandescent  bodies,  such  as  iron  and 
phosphorus,  and  from  the  action  of  acids  or  caustic  alka- 
lies, whether  projected  accidentally — for  example,  during 
their  manufacture — or  purposely  thrown  with  criminal  in- 
tent (vitriol)." 

Contusions  more  frequently  affect  the  edges  of  the 
orbit  and  the  nose  than  the  eyelids.  By  reason  of  the  great 
vascularity  and  the  laxity  of  the  palpebral  areolar  tissue 
they  are  generally  accompanied  by  free  extravasations  of 
blood,  either  in  the  form  of  diffused  ecchymoses  or  of  hem- 
atomata.  In  their  differential  diagnosis  it  is  necessary  to 
distinguish  those  forms  of  infiltration  which  appear  imme- 
diately after  traumatism  from  the  later-appearing  ecchy- 
moses that  are  symptomatic  of  fracture  of  the  anterior  wall 
of  the  skull  or  are  expressive  of  rupture  of  the  deep  orbital 
vessels.     The  former  conditions  are  more  unsightly  than 


Traumatic  Lesions  of  the  Ocular  Adnexa.  11 

important,  but  in  the  latter  the  patient  should  be  placed 
nnder  a  prolonged  period  of  observation  before  any  definite 
prognosis  can  be  given. 

Wounds  made  by  pointed  instruments  heal  rapidly 
and  often  without  scars.  It  must  not  be  forgotten,  how- 
ever, that  they  may  involve  the  eyeball  or  injure  the  con- 
tents of  the  orbit,  especially  the  tissues  of  the  optic  nerve. 
Medical  literature  contains  many  instances  in  which  sharp 
objects — such  as  fragments  of  wood,  steel,  and  lead — have 
penetrated  into  the  orbital  tissues  and  have  remained  im- 
bedded, leaving  barely-perceptible  scars. 

A  horizontal  wound,  produced  by  an  aseptic  cutting 
instrument,  even  when  extensive,  usually  heals  without 
deformity,  unless  the  suspensory  ligament  of  the  upper 
eyelid  be  cut.  In  such  cases,  if  the  detached  end  of  the 
levator  of  the  lid  is  not  successfully  sutured  to  the  tarsus, 
the  resulting  ptosis  becomes  permanent.  Vertical  or  very 
oblique  incisions  which  include  the  entire  thickness  of  the 
eyelid,  and  its  free  margin,  lead,  when  union  by  first  in- 
tention is  delayed,  to  coloboma,  ectropion,  entropion,  tri- 
chiasis, etc.  Division  of  the  internal  palpebral  ligament  or 
of  the  canaliculi  may  disturb  the  function  of  the  lacrymal 
apparatus.  If  the  ocular  conjunctiva  is  cut,  marked  lim- 
itation of  the  movement  of  globe  and  lids  may  ultimately 
result  from  a  consequent  symblepharon.  The  tears  that  are 
sometimes  produced  by  blunt  implements  are  rarely  of  more 
gravity  than  those  that  have  resulted  from  cutting  instru- 
ments, and,  unless  the  parts  are  too  much  crushed,  primary 
union  may  be  obtained  by  careful  suturing.  The  following 
case  proves  this: — 

Case  III  (personal  and  unpublished). — Extensive  laceration 
of  the  lower  eyelid  by  a  blow  from  a  fist.  Suture.  Healing  by 
first   intention. 


12  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

In  May,  1880,  N.  J.,  a  horse-trainer,  during  an  altercation 
with  one  of  his  comrades,  received  a  violent  blow  on  the  right 
eye.  Compresses  of  dilute  tincture  of  aniica  were  applied.  The 
author  saw  the  patient  forty-eiglit  hours  later.  In  addition  to  an 
ecchymotic  swelling  of  the  lids  and  the  root  of  the  nose  and  the 
cheek,  there  was  a  wound  beginning  at  the  internal  canthus,  which 
involved  the  lower  eyelid,  at  a  distance  of  three  centimeters  from 
its  free  border.  After  a  careful  cleansing  of  the  injured  region, 
four  sutures  were  applied.  The  stitches  were  removed  on  the  third 
day,  primary  union  having  been  secured  throughout.  When  seen 
later  the  eyelid  was  found  to  be  in  good  position,  and  although 
the  lacrj-mal  duct  was  obstructed  the  patient  did  not  complain  of 
any  epiphora. 

Infinitely  more  dangerous  are  extensive  contused 
wounds  with  ragged,  uneven  edges.  This  is  so,  as  such 
wounds  rarely  unite  by  first  intention,  and  are  too  often 
complicated  by  suppuration,  erysipelas,  and  gangrene.  In 
addition,  cicatricial  deformities — such  as  ectropion,  en- 
tropion, and  trichiasis — may  all  appear  as  consequences. 
Although  some  of  these  subsequent  conditions  are  in  part 
curable  by  operative  procedure,  yet  the  nature  of  the  injury 
is  none  the  less  important.  The  possibility  of  extension 
of  phlegmon  or  of  erysipelas  to  the  orbital  cavity,  the  pro- 
duction of  a  thrombophlebitis  (an  exceedingly  serious  le- 
sion), and  the  occasional  occurrence  of  amblyopia  and 
amaurosis  must  all  be  considered.  Schwendt^-  reports 
seven  cases  of  amblyopia  and  two  of  amaurosis  as  appear- 
ing in  forty-four  cases  of  erysipelatous  phlegmon  of  the 
orbit.  These  types  of  traumatism  are  often  aggravated  by 
the  presence  of  a  foreign  body — such  as  a  fragment  of  lead, 
wood,  and  metal — which,  after  closure  of  the  wound,  may 
become  encysted  in  the  loose  cellular  tissues  of  the  eyelid, 
or  become  the  starting-point  for  inflammatory  conditions 
whose  repetition  and  persistence  have  a  special  semeio- 
logical  significance. 


Traumatic  Lesions  of  the  Ocular  Adnexa.  13 

Burns  of  the  so-called  first  and  of  the  second  degrees 
give  rise  to  scarcely  any  deformity.  Grains  of  powder  that 
are  not  immediately  removed  leave  indelible  black  stains  of 
carbon.  In  the  acute  condition  the  eyelids  may  be  consid- 
erably swelled.  Deep  burns  may  destroy  the  skin,  the  sub- 
cutaneous areolar  tissue,  the  fibers  of  the  orbicularis  mus- 
cle, etc.  In  such  cases  the  resultant  eschars  are  followed 
by  cicatricial  contraction,  displacement  of  the  lid-borders, 
adhesion  of  the  free  edges  of  the  eyelids,  and  even  attach- 
ment of  the  ocular  and  palpebral  conjunctivae.  These  con- 
ditions are  more  serious  when  the  ocular  conjunctiva  and 
the  eyeball  itself  are  simultaneously  involved.  There  are 
rare  cases  in  which  the  eyelids  have  been  completely  de- 
stroyed. 

In  brief,  superficial  and  isolated  burns  and  simple 
wounds  caused  by  pointed  or  cutting  instruments  heal 
rapidly  without  serious  results.  On  the  contrary,  deep 
burns,  severe  contused  wounds,  especially  those  that  are 
produced  by  fire-arms,  are  dangerous.  They  incapacitate  the 
patient  for  work  for  a  period  of  some  weeks,  and  their  com- 
plications at  times  are  so  severe  as  to  threaten  life.  They 
always  entail  deformities  that  are  more  or  less  incurable 
and  are  detrimental  to  vision. 

As  a  rule,  the  color  of  the  eschar  is  an  indication  of 
the  nature  of  the  caustic  agent,  that  of  nitric  and  hydro- 
chloric acids,  for  example,  being  yellow,  while  that  of  caus- 
tic potash  and  sulphuric  acid  is  blackish  in  tint. 

(C)    CONJUNCTIVA. 

Wounds,  foreign  bodies,  and  burns  of  the  cornea  and 
conjunctiva  are  of  daily  occurrence,  especially  in  industrial 
centers.    Frequently  the  lids  are  wounded,  and  occasionally 


14  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

a  muscle  is  injured  at  the  same  time.  Ordinarily  the  phy- 
sician sees  but  a  small  percentage  of  cases  of  this  type. 
Slight  burns  of  the  conjunctivas,  such  as  those  that  are 
caused  by  minute  incandescent  particles  of  iron,  chipped 
off  by  a  hammer,  produce  only  slight  injection;  these  heal 
after  a  few  days'  rest  with  the  application  of  cold  com- 
presses. Frequently  a  great  number  of  small  foreign  bodies 
are  expelled  almost  as  soon  as  they  strike  the  membrane, 
this  being  accomplished  by  the  natural  movements  of  the 
eyelids  and  by  the  efforts  of  the  patient.  At  other  times, 
fellow-workmen  succeed  in  freeing  the  eye  from  foreign 
particles  that  may  be  lying  free  in  the  conjunctival  sac. 
Blunt  bodies,  such  as  chippings  from  iron  castings, 
flying,  without  much  force,  against  the  lids,  or  driven 
directly  against  the  conjunctival  membrane,  often  con- 
tuse the  conjunctiva  without  producing  deeper  injuries. 
Generally  an  ecchymosis,  which  immediately  elevates  the 
conjunctiva,  appears,  and,  in  accordance  with  its  degree, 
gives  rise  either  to  a  simple  suffusion  or  to  a  thrombus 
which  may  extend  beneath  the  bulbar  mucous  membrane. 
At  times,  a  ring  of  chemosis  situated  around  the  cornea 
may  be  formed.  If  the  injury  is  slight,  a  resorption  of  a 
subconjunctival  ecchymosis  generally  takes  place  in  one 
or  two  weeks'  time.  Extensive  extravasations  may  im- 
pair the  nutrition  of  the  cornea,  by  compression,  and  ex- 
ceptionally they  may  produce  a  rupture  of  the  mucous 
membrane,  thus  leading  to  the  formation  of  localized  ab- 
scesses. Here,  too,  care  should  be  taken  not  to  confound 
such  extravasations  with  those  that  are  due  to  fracture  of 
the  orbit  or  of  the  base  of  the  skull.  As  a  rule,  the  latter 
do  not  appear  until  several  days  after  the  accident,  involv- 
ing first  the  inferior  cul-de-sac,  and  then  spreading  be- 
neath the  bulbar  conjunctiva.     A  subconjunctival  ecchy- 


Traumatic  Lesions  of  the  Ocular  Adnexa.  15 

mosis  may  rarely  conceal  a  wound  of  the  subjacent  sclera; 
but,  in  such  cases,  other  objective  and  functional  symp- 
toms will  show  that  the  conjunctiva  is  not  alone  involved. 

Wounds  of  the  conjunctiva  caused  by  sharp  objects 
have  the  appearance  of  surgical  incisions,  and  heal  in  sev- 
eral days'  time,  particularly  if  the  offending  agent  is  aseptic 
and  the  wound  is  perpendicular  or  very  oblique.  Should 
there  be  the  formation  of  a  flap,  even  if  the  wound  is  trans- 
verse, the  gravity  of  the  prognosis  is  not  increased,  unless 
the  pedicle  is  very  narrow.  A  large  denudation  of  the  sclera 
by  death  of  a  broad  conjunctival  flap  is,  nevertheless,  an 
unfavorable  complication,  for,  beside  the  slowness  in  heal- 
ing, the  loss  of  substance,  unless  great  care  be  taken,  gives 
rise  to  a  considerable  shortening  of  the  conjunctival  mem- 
brane; moreover,  when  there  is  a  loss  of  substance  at  a 
corresponding  point  of  the  palpebral  conjunctiva  the  two 
parts  unite,  and  produce  a  complication,  the  gravity  of 
which  will  be  shown  in  the  section  on  burns  of  the  con- 
junctiva. Similar  consequences  follow  contused  wounds, 
which  are,  however,  generally  accompanied  by  serious  le- 
sions of  the  subjacent  tissues. 

The  prognosis  of  injuries  of  the  conjunctiva  due  to 
foreign  bodies  is  very  favorable. ^^  The  inflammation, 
the  blepharospasm,  and  the  pain,  that  indicate  their  pres- 
ence, all  disappear  as  if  by  magic  after  the  removal  of  the 
foreign  material.  Eelatively  large  foreign  bodies  may  re- 
main for  months  and  even  years  hidden  in  the  hyper- 
trophied  folds  of  the  conjunctival  cul-de-sac  without  pro- 
ducing any  other  symptoms  than  those  of  slight  discomfort, 
swelling  of  the  eyelid,  and  chronic  irritation,  which  is  ac- 
companied by  a  muco-puTulent  discharge. 

FraenkeP'*  cites  a  case  in  which  a  piece  of  wood,  fifteen 
millimeters  in  length  and  fifteen  millimeters  broad,  had 


1(3  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

lain  in  a  conjunctival  cul-de-sac  for  twelve  years.  Similarly, 
grains  of  lead  or  of  powder  and  small  pieces  of  glass  may 
become  encysted  in  the  bulbar  conjunctiva,  and  be  very 
easily  tolerated.  In  another  publication^^  the  author  has 
recorded  the  discovery  of  a  piece  of  glass,  three  millimeters 
long,  in  the  center  of  a  fungous  vegetation  of  the  semilunar 
fold.  The  patient  remembered  that  he  had  been  wounded 
eight  years  before  by  the  breaking  of  a  bottle  which  he 
was  corking.  He  had  never  suffered  from  the  excrescence, 
coming  to  the  author  to  have  it  removed  merely  because  it 
was  increasing  in  size  and  bled  on  the  slightest  touch. 

Burns  of  the  conjunctiva^®  are  usually  complicated 
by  similar  conditions  of  the  lid,  of  the  sclera,  and  of  the 
cornea;  and,  in  consequence,  they  are  generally  serious  in 
character.  As  a  rule,  they  are  the  result  of  the  action  of 
steam,  alcohol-flames,  gas,  etc.  Frequently  they  are  pro- 
duced by  chemical  agents,  acids,  alkalies,  heated  and  in- 
candescent solids  such  as  metallic  particles,  charcoal,  fused 
wax,  pitch,  boiling  oil,  heated  water,  and  phosphorus.  On 
account  of  their  diffusibility,  chemical  agents  spread  more 
rapidly  and  extensively  to  the  surrounding  tissues;  they 
do  not,  however,  burn  so  deeply  as  substances  in  a  state  of 
ignition. 

Acids  (hydrochloric,  nitric,  and  sulphuric)  are  fre- 
quently thrown  into  the  eye  either  by  accident  or  intent. 
They  often  produce  injuries  the  depth  and  the  gravity  of 
which  are  jDroportionate  to  the  concentration  of  the  ma- 
terial and  to  the  duration  of  the  primary  burning.  Per- 
foration of  the  globe  may  result  from  destruction  of  the 
subjacent  sclera  and  of  the  cornea,  and  the  eye  may  be 
lost.  Burns  by  mortar  are  common,  but  if  the  foreign 
substance  is  not  very  caustic,  and  if  it  is  removed  at  once, 
any  resultant  conjunctival  inflammation  heals  rapidly  and 


Traumatic  Leslniift  of  the  Ocular  Adnexa.  3^7 

the  patient  will  be  able  to  resume  work  in  a  few  days' 
time.  Tbe  results,  however,  are  diflEerent  when  deep  burns 
are  produced  by  quick-lime  or  l)y  acids.  In  addition  to 
a  possible  perforation  of  the  eyeball  and  the  evacuation 
of  its  contents,  more  or  less  extensive  adhesions  between 
the  lids  and  the  eyeball  (symblepharon,  ankyloblepharon, 
etc.)  may  be  formed:  conditions  which  are  often  incurable 
and  frequently  disturb  the  function  of  the  organ.  It  is 
important  to  determine  whether  the  conjunctival  cul-de-sac 
has  escaped  injury,  for,  in  many  instances  if  a  symblepharon 
is  incomplete,  it  may  be  readily  removed  by  judicious  treat- 
ment, and  the  earning  capacity  of  the  patient  will  not  be 
appreciably  diminished,  as  the  following  case  illustrates: — 

Case  IV  (personal  and  unpublished). — Burn  of  the  conjunc- 
tiva by  a  boiling  solution  of  potash.  Partial  symblepharon,  with 
traumatic  pterygium. 

On  December  27,  189  -,  the  author  made  an  examination  of 
X,  a  20-year-old  man  who  was  injured  on  the  30th  of  June,  of  the 
same  year,  by  a  boiling  potash  solution,  to  determine  (1)  the 
existence  of  a  permanent  lesion  of  the  right  eye,  (2)  its  nature, 
and  (3)  its  effect  upon  the  earning  capacity  of  the  patient. 
X  resumed  his  work  eleven  days  after  the  accident,  and  claimed 
heavy  damages  for  the  injury.  Examination  revealed  the  pres- 
ence of  a  loose  band  of  adhesion  situated  between  a  point  of  the 
lower  lid  and  the  eyeball  on  the  right  side,  and  of  the  existence 
of  a  fibrous  extension  in  the  form  of  a  pterygium,  which  occupied 
the  infero-external  part  of  the  bulbar  conjunctiva,  the  latter  en- 
croaching, for  a  distance  of  two  millimeters,  upon  the  correspond- 
ing part  of  the  cornea.  Examination  with  oblique  illumination 
and  with  the  ophthalmoscope  failed  to  show  any  other  lesion  of 
the  cornea,  of  the  media,  or  of  the  deeper  portions  of  the  eye. 
Central  and  peripheral  visual  acuities  were  normal.  There  was 
neither  strabismus  nor  limitation  of  the  movements  of  the  globe 
in  any  direction.  The  wage  value  of  the  patient  was  consequently 
but  little  decreased  by  the  traumatism,  which  did  not  impair  any 
of  the  essential  functions  of  the  organ. 


Ig  Injuries  to  fhc  Eye  in  their  Medico-legal  Aspect. 

However,  as  cicatricial  tissue  in  time  undergoes  spe- 
cial changes,  it  is  always  necessary  to  wait  several  months 
before  deciding  definitely  upon  the  amount  of  ultimate 
contraction  of  such  bands,  and  of  the  consequent  limitation 
of  the  movements  of  the  eye.     • 

Burns  by  alcohol-flames,  which  the  author  has  seen 
in  men  while  engaged  in  welding  metals,  have  been  super- 
ficial, and  do  not  require  special  mention.  Those  that 
are  produced  by  steam  from  the  bursting  of  steam-pipes, 
boilers,  etc.,  are  often  complicated  by  more  severe  lesions, 
which  are  due  to  flying  pieces  of  metal  or  glass.  The 
violence  of  the  action  of  fused  or  incandescent  bodies  de- 
pends upon  their  temperature.  Burns  by  iron  dross, 
wrought  iron,  or  fused  brass  and  steel,  the  temperatures 
of  which  are  always  above  1000°  C,  are  common  among 
blacksmiths,  rollers,  and  smelters.  They  are  ordinarily 
quite  deep,  and  lead  either  to  the  loss  of  the  eye  or  to  ex- 
tensive cicatrization. 

Drops  of  metals  that  fuse  at  low  temperatures — such 
as  lead,  zinc,  tin,  and  antimony — may  enter  the  conjunctival 
sac  without  producing  serious  lesions.  An  ingenious  ex- 
planation has  been  given  for  this  fact  by  Ferrier.^'^  In 
accordance  with  a  phenomenon,  known  in  physics  under 
the  name  of  calefaction,  the  tissues  are  separated  from  the 
metal  by  a  cushion  of  gas  that  is  produced  by  a  sudden 
evaporation  of  the  fluids  on  the  surface  of  the  eye,  and  are 
no  longer  exposed  to  the  heat  of  the  fused  metal.  In  ad- 
dition to  others,  the  author  has  published  several  cases  of 
such  superficial  burns. ^^ 


CHAPTER  II. 

Oebit  and  its  Contents.^^ 

The  gravity  of  traumatisms  of  the  orbit  is  most  vari- 
able on  account  of  the  importance  and  the  multiplicit}'' 
of  the  tissues  which  compose  tliis  region  and  also  by  reason 
of  the  proximity  of  the  cranium.  The  maximum  degree 
of  severity  is  reached  when  the  eyeball  at  the  same  time 
is  injured,  or  when  the  wounding  agent  penetrates  the 
cranial  cavity.  In  practice,  traumatisms  of  the  orbit  are 
frequently  complex  in  character;  that  is,  the  lesions  of 
the  soft  parts  are  complicated  by  fracture  of  the  orbital 
wall  or  by  the  presence  of  a  foreign  body;  but  for  clear- 
ness of  demonstration  it  is  customary  to  consider  success- 
ively traumatic  lesions:  (a)  of  the-  orMtal  vails  (b)  of  the 
soft  parts  of  the  orlit. 

(a)  orbital  walls. 

In  the  study  of  the  traumatic  lesions  of  the  eyebrow 
aud  lids,  which  has  just  been  made,  it  was  seen  that  blunt 
instruments  striking  the  orbital  edge  produce,  according 
to  the  violence  of  the  traumatism,  subcutaneous,  subapo- 
neurotic, or,  more  rarely,  subperiosteal  hemorrhages.  It 
will  also  be  noticed  that  a  linear  division  of  the  soft  parts 
may  be  made  from  within  outward,  and  that  it  may  be 
accompanied  by  a  denudation  of  the  bone  which  is  often 
followed  by  prolonged  suppuration,  orbital  phlegmon,  or 
severe  cranio-facial  erysipelas.     In  addition,  there  mav  be 

(19)" 


20  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

a  radiating  fracture  in  the  corresponding  wall,  and  finally 
various  functional  disturbances — such  as  neuralgia,  anes- 
thesia, and  amblyopia — may  appear. 

In  general,  moderate  contusion  of  the  base  of  the 
orbit  gives  rise  only  to  bloody  suffusion,  which  distends 
the  lids,  spreads  across  the  face,  and  occasionally  reaches 
the  other  side.  Complete  absorption  of  the  blood  is  the 
rule,  but  in  some  instances  the  effusion  may  persist  and 
produce  slight- periosteal  indurations  or  neuralgic  pains. 

Prognosis  is  unfavorable  when  the  traumatism  has 
stripped  the  periosteum  and  has  produced  a  fracture  of  the 
orbital  walls.  This  point  has  already  been  siifficiently 
dwelt  upon.  It  is  necessary,  from  both  a  diagnostic  and  a 
prognostic  point  of  view,  to  remark  here,  however,  that 
the  appearance  of  an  orbital  liematoma,  after  contusion 
of  the  orbital  edge,  implies  the  existence  of  an  injury  to 
the  cavity  itself,  as  the  tarso-orbital  fascia  is  closely  at- 
tached to  the  bone,  and  prevents  the  spreading  "backward 
of  any  superficial  extravasation. 

A  loss  of  substance  that  is  limited  to  the  edge  of  the 
orbit  is  very  rare,  and,  as  a  rule,  can  only  occur  when  the 
wounding  agent  merely  grazes  the  bone.  The  diagnosis 
must  be  made  on  symptoms  that  vary  with  the  position  of 
the  traumatism;  slight  emphysema,  in  case  of  the  opening 
of  a  sinus;  anesthesia  of  one-half  of  the  upper  lip,  and  of 
the  corresponding  ala  of  the  nose,  if  the  supraorbital  nerve 
has  been  injured  by  the  separation  of  the  zygomatic-max- 
illary  suture  or  by  fracture  of  the  floor  of  the  orbit-^;  ob- 
struction of  the  upper  part  of  the  nasal  duct  by  a  fragment 
of  bone-^;    and,  finally,  cicatricial  ectropion  (Mackenzie). 

As  a  rule,  one  or  more  of  the  Avails  of  the  orbit  are 
involved  in  an  injury  to  the  orbital  edge.  Extension  to  the 
thin  bone  forming  the  vault  of  the  cavity  is  the  most  impor- 


Traumatic  Lesions  of  the  Ocular  Adnexa.  31 

tant,  because  of  the  immediate  proximity  of  the  meninges 
and  of  the  possible  development  of  a  fatal  meningo-enceph- 
alitis.  However,  Berlin's  statistics  show  that,  out  of  19 
cases  of  simultaneous  fractures  of  the  edge  of  the  orbit  and 
of  the  vault,  there  were  IG  recoveries;  while  52  cases  of 
fractures  limited  to  the  superior  wall  were  followed  by  41 
deaths.  In  the  first  series  of  cases  the  violence  of  the  trau- 
matism was  probal)ly  neutralized,  in  part,  by  the  prominence 
and  the  resistance  of  the  edge  of  the  orbit. 

As  a  rule,  all  interest  in  injuries  to  the  orbital  wall 
centers  in  fractures.  Those  caused  indirectly  take  place 
either  by  contrecoup  or  more  frequently  as  the  result  of  an 
extension  of  fractures  of  the  superior  maxillary  or  malar 
bones,  this  being  especially  true  for  the  middle  or  the  ante- 
rior fossa  of  the  skull,  and  in  falls  on  the  head  or  in  crushing 
injuries  of  the  face  and  temples.  In  96  cases  of  fractures 
of  the  base  of  the  skull,  due  to  shot  wounds  or  to  falls. 
Holder  found  fractures  of  the  vault  of  the  orbit  in  73  in- 
stances; involvement  of  the  superior  or  internal  wall  of 
the  optic  canal  53  times;  subvaginal  extravasation  of 
blood  in  42  cases;  complete  unilateral  blindness  in  27 
cases;   and  incomplete  amaurosis  in  4. 

The  effect  upon  the  vision  will  be  the  more  serious  if 
the  optic  nerve  and  its  sheath  are  violently  torn  and  com- 
pressed,— aside  from  the  gravity  of  the  cerebral  lesions, 
which  depend  upon  fracture  of  the  skull.  Absolute  blind- 
ness, discovered  immediately  after  the  return  of  the  patient 
to  consciousness,  with  or  without  ophthalmoscopic  appear-  . 
ances  of  papillary  stasis  or  of  hemorrhages  in  the  retina  and 
vitreous,  serves  for  a  l)ad  prognosis;  while  the  preservation 
of  a  part  of  the  peripheral  visual  field  gives  hope  of  the 
return  of  a  relative  amount  of  visual  acuity. 

Finally,  paralysis  in  one  or  more  of  the  muscles  indi- 


22  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

cates  the  probable  involvement  of  the  sphenoidal  fissure, 
and  it  will  be  seen  later  that,  aside  from  traumatisms  of 
the  cranium,  those  of  tlie  orbital  region  (contusions, 
foreign  bodies,  etc.)  have  an  important  bearing  on  the 
etiology  of  paralysis  of  tlie  eye-muscles.^-  Casper  has  pub- 
lished a  case  of  paresis  of  tlic  internal  rectus  and  the 
superior  oblique  muscles  tluit  was  due  to  the  penetration 
of  a  cutting  instrument  into  the  upper,  internal  part  of 
the  orbit.  Grevin  has  seen  an  instance  of  paralysis  of  the 
superior  oblique  muscle  the  result  of  a  contusion  of  the 
orbital  edge. 

Direct  fractures  are  quite  frequent,  and  are,  as  a 
rule,  produced  by  ])rojectiles  and  jioiutcd  ol)jects, — such 
as  swords,  naked  foils,  forks,  and  files.  They  are  also  fre- 
quently caused  l)y  thrusts  from  the  horns  of  cows,  the  ends 
of  canes,  and  umbrella-sticks.  The  wounding  body  may 
penetrate  into  a  sinus  or  the  cerebral  cavity  or  into  the 
nasal  fossa'.  It  may  also  ])ass  into  the  opposite  orbit  and 
produce  important  and  complex  organic  or  functional  dis- 
orders. The  external  orbital  wall  is  particularly  liable  to 
fi'acture  by  projectiles  from  fire-arms.  The  mass  may  either 
simply  shatter  the  wall  and  displace  the  eye  forward  and 
inward  or  it  may  emerge  fi-oin  the  opposite  temple,  after 
having  severed  the  optic  nerve  or  destroyed  the  eyeball. 
A  pointed  instrument,  such  as  a  fragment  of  wood  (do 
Wecker-^)  may  easily  perforate  the  internal  wall,  and  enter 
either  the  nasal  fossa  or  the  neighboring  sinuses,  producing 
epistaxis  and  emphysema  of  the  orbit  and  lids.  If  tlio 
globe  has  not  been  involved,  and  if  the  wound  is  not  in- 
fected, the  patient  is,  as  a  rule,  merely  incapacitated  for 
work  for  a  brief  period  of  time. 

Mucb  moi'c  scricnis  is  the  rt'sidl  of  a  direct  fracture  of 
the  superior  wall  of  the  orbit.    Such  a  traumatism  involves 


Traumatic  Lesions  of  the  Ocular  Adncni.  23 

the  optic  canal  in  more  than  one-half  of  the  cases;  and, 
according  to  Berlin's  figures,  shows  a  mortality  of  80  per 
cent.  Lesions  of  the  internal  carotid  artery,  the  cavernons 
sinus,  and  the  anterior  cerebral  artery,  as  a  rule,  produce 
sudden  death.  In  some  other  cases  the  patient  succumbs 
later  to  an  infectious  meningo-encephalitis  and  suppurative 
thrombophlebitis,  or,  if  the  carotid  artery  has  been  wounded 
in  the  cavernous  sinus,  he  may  soon  evidence  an  arterio- 
venovis  aneurism. 

The  character  of  treatment  that  is  employed  at  the 
present  day  allows  many  of  these  severe  forms  of  trauma- 
tism to  terminate  happily,  even  when  they  have  been  at 
first  complicated  by  alarming  cerebral  symptoms;  in  fact, 
some  such  cases  have  been  mentioned  in  medical  literature 
long  before  the  era  of  asepsis  and  antisepsis. 

Although  the  diagnosis  of  such  fractures  is  often  ob- 
scure, exploration  with  a  probe  should,  as  a  rule,  be  avoided, 
for  the  condition  of  the  patient  nuiy  be  fatally  aggravated 
either  by  infection  or  by  the  displacing  of  a  foreign  material 
— for  example,  a  bony  splinter — into  the  cranial  cavity. 

(b)  injuries  to  the  soft  parts  of  the  orbit. 

It  is  well  known  that  as  a  result  of  the  shape  and  the 
free  mobility  of  the  eyeball  a  wounding  object  may  pass 
around  its  fibrous  sheath  and  produce  an  injury  of  the  sur- 
rounding soft  parts  of  the  orbit  only.  The  importance  of 
such  a  form  of  traumatism  depends,  above  all,  on  the  clean- 
liness of  the  penetrating  body,  its  degree  of  bluntness,  and 
whether  it  has  a  pointed  or  a  cutting  edge.  If  the  offending 
instrument  has  not  been  freed  from  septic  material  while 
passing  through  the  skin,  the  conjunctiva,  and  the  orbital 
septum,  it  may  act  as  the  cause  of  a  cellulitis  and  its  dan- 
gers, not  only  for  the  preservation  of  vision  (amaurosis  by 


24  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

atrophy,  etc.),  but  also  for  the  life  of  the  patient  (for  ex- 
ample, by  thrombosis  of  the  ophthalmic  veins  and  of  the 
sinuses).  Section  of  the  ophthalmic  vessels,  rupture  of  the 
ocular  muscles,  injuries  to  the  sensory  and  the  motor  nerves, 
and  the  presence  of  foreign  bodies  are  among  the  most  in- 
teresting lesions  of  the  soft  parts  of  the  orbit. 

Laceration  of  the  arteries,  veins,  and  capillaries  is 
rapidly  followed  by  an  extravasation  of  blood,  which  infil- 
trates the  orbital  cavity,  passing  into  Tenon's  space  and 
the  subconjunctival  cellular  tissues,  producing  an  exoph- 
thalmos, the  degree  of  which  varies  with  the  extent  of 
the  hemorrhage.  Later,  a  palpebral  ecchymosis  appears. 
As  a  rule,  several  weeks  suffice  for  the  absorption  of  the 
blood,  but  excessive  compression  from  the  effusion  has,  at 
times,  led  to  a  phthisis  bulbi  (Berlin).  Gepner  reports  a 
case  of  neuroretinitis,  with  atrophy  of  the  optic  nerve,  as 
the  result  of  an  intraorbital  hemorrhage.-* 

Eupture  of  an  ocular  muscle,  detachment  of  its  ten- 
don from  its  insertion  into  the  sclera,  and  injury  to  a 
motor  nerve  are  all  relatively  rare  types  of  injury.  The 
result,  in  each  instance,  will  be  a  traumatic  paralysis,  with 
strabismus  and  diplopia,  which,  aside  from  the  vertigo  and 
the  disturbances  in  gait  that  it  entails,  is  always  a  serious 
obstacle  to  work,  and  considerably  reduces  the  earning  ca- 
pacity of  the  individual.  It  is  true  that  this  double  vision 
can,  as  a  rule,  be  fairly  well  corrected  by  an  operation  or  by 
the  use  of  appropriate  prisms.  This  correction,  however,  is 
often  far  from  being  satisfactory,  and,  as  a  rule,  the  patient 
is  compelled  to  wear  a  ground-glass  before  the  affected  eye, 
unless  he  gradually  learns  to  disregard  one  of  the  sensory 
images.  At  times,  consequently,  the  effect  of  the  injury  is 
very  severe,  becoming  almost  equivalent  to  the  ;functional 
loss  of  an  eve. 


Traumatic  Lesions  of  the  Ocular  Adnexa.  25 

In  injuries  to  the  optic  nerve  by  the  extension  of 
fractures  of  the  vault  of  the  orbit  into  the  optic  canal,  the 
deep  situation,  the  great  length,  and  the  curved  direction 
of  the  orbital  portion  of  the  nerve  keep  this  part  fairl}^  well 
protected  against  direct  violence.  Its  intracranial  part  is 
still  more  rarely  involved,  but  in  such  a  form  of  accident, 
however,  the  patient  seldom  survives.-^ 

It  is  possible  for  an  injury  to  the  optic  nerve  to  take 
place  from  the  thrust  of  a  sword,  a  foil,  a  knife,  a  scissors, 
an  awl,  an  umbrella-stick,  a  horn,  etc.;  or  as  the  result  of 
shot  and  bullet  wounds.  In  such  cases  the  nerve,  as  a  rule, 
is  either  bruised,  torn,  or  cut  by  the  instrument  after  it 
has  passed  through  the  globe  or  has  gone  between  it  and 
the  orbital  walls.  Sometimes,  the  projectile,  whose  wound 
of  entrance  may  be  easily  overlooked,  passes  so  obliquely 
backward  as  to  injure  the  optic  nerve  of  the  opposite  side, 
and  so  produces  a  crossed  type  of  amaurosis  (see  cases  of 
Jodko,  Leber,  and  Panas).  All  of  these  types  of  trauma- 
tism are  verv  serious.  The  immediate  and  total  abolition 
of  sight  generally  remains  permanent,  except  when  the  optic 
nerve  has  been  but  slightly  contused  or  compressed;  though 
even  in  such  cases  there  is  the  danger  of  secondary  atrophy 
from  traumatic  neuritis. 

The  nature  of  the  foreign  bodies  (projectiles,  frag- 
ments of  glass,  wood,  sword-foils,  knife-blades,  etc.)  which 
penetrate  the  orbital  cavit}^,  during  quarrels,  criminal  as- 
saults, and  falls  varies  greatly.^*^  As  a  general  rule,  even 
when  they  are  of  considerable  size  they  are  readily  toler- 
ated, provided  they  are  aseptic  in  character.  They  ulti- 
mately become  encysted,  and  produce  only  a  certain  de- 
gree of  exophthalmos  or  a  deviation  of  the  eye.  There  are 
numerous  instances  in  which  their  presence  has  not  been 
suspected.     To  the  well-known  case  of  Higgens  may  be 


26  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

added  the  account,  published  by  Eoose,  of  an  old  man,  who 
had  been  wounded  at  Sedan,  and  had  carried  a  leaden 
bullet  two  and  a  half  centimeters  long,  and  thirty-two 
grammes  in  weight,  in  his  orbit  for  a  period  of  twenty- 
two  years.-"  Panas,  likewise,  cites  an  instance  in  which  an 
officer  had  unconsciously  borne  a  cylindro-conical  ball  in 
the  orbital  cavity  for  more  than  ten  years'  time. 

Sometimes,  on  the  other  hand,  grave  complications — ■ 
such  as  phlegmon,  thrombophlebitis,  erysipelas,  meningo- 
encephalitis, fatal  tetanus,-^  complete  blindness,  paralytic 
strabismus  with  diplopia — -may  appear  as  a  result  of  infec- 
tion of  the  wound  or  injury  to  the  eyeball,  the  optic  nerve, 
the  motor  nerves,  or  the  brain.  Wicherkiewicz  reports  a 
case  of  a  child,  8  years  of  age,  who  had  fallen  upon  some 
branches  and  had  forced  a  small  twig  of  wood  into  her 
orbit,  without  injuring  the  eye.  On  the  following  day 
the  child  succumbed  to  an  attack  of  acute  suppurative  men- 
ingitis. The  autopsy  showed  that  the  piece  of  wood,  which 
had  been  removed  on  the  day  of  the  accident,  had  perforated 
the  cribriform  plate  of  the  ethmoid  bone,  and  had  wounded 
the  brain  near  the  olfactory  nerve  as  well  as  completely 
crushing  the  optic  nerve.-" 

Prognosis  should  consequently  be  very  reserved,  aud  it 
must  not  be  forgotten  that  the  removal  of  foreign  bodies 
that  are  firmly  fixed  in  the  bony  walls,  or  extend  into  the 
cranial  cavity,  exposes  the  patient  to  the  chance  of  fatal 
complications  (see  eases  of  Pagenstecher,  Demours,  etc.). 

The  report^"  published  l)y  the  author  several  years 
ago,  of  an  hysterical  servant-girl  who  daily  introduced 
pieces  of  glass  into  her  right  lower  cul-de-sac  and  orbit  in 
order  to  irritate  the  eye,  and  simulated  blindness  so  as  to 
be  able  to  claim  heavy  damages,  is  sufficiently  interesting 
in  this  connection  to  deserve  notice. 


Traumatic  Lesions  of  the  Ocular  Adnexa.  27 

Case  V  (personal). — Introduction  of  numerous  pieces  of  glass 
into  the  orbit. 

Miss  X,  32  years  of  age,  came  to  my  office  witli  the  right  eye 
covered  with  blood  and  complaining  of  severe  pain.  She  begged 
me  to  remove  several  pieces  of  glass  from  behind  the  eyeball, 
which  she  said  had  entered  the  orbit  two  years  before.  From 
information  obtained  from  the  patient,  and  from  the  physicians 
who  had  previously  treated  her,  the  following  history  was  elicited: 

Family  history  negative:  her  father,  mother,  three  brothers, 
and  two  sisters  were  living  and  were  all  in  good  health.  None  of 
them  had  suffered  from  nen'ous  affections. 

Menstruation  was  established  at  the  age  of  twelve  years,  and 
was  always  regular.  The  patient  knew  she  had  a  whimsical  and 
irritable  nature,  but  never  had  had  any  nervous  attacks.  After 
several  improbable  accounts,  she  finally  admitted  that,  in  the 
course  of  a  dispute,  she  had  been  struck  in  the  face  by  a  glass  of 
beer  by  her  drunken  master.  The  pieces  had  entered  both  eyes, 
but  chiefly  the  right  one.  During  several  months  following  the 
accident  a  physician  had  removed  six  or  seven  jjieces  of  glass,  all 
having  a  greater  length  than  width,  and  each  some  two  centi- 
meters long.  The  right  eye  was  attacked  by  an  iritis,  and  vision 
became  markedly  reduced.  The  physician  losing  her  confidence, 
by  causing  too  much  pain  during  his  examination,  she  had  her 
master,  by  means  of  a  curette  and  by  irrigations  of  warm  water, 
remove  some  additional  pieces  that  could  be  felt  at  the  level  of  the 
supraorbital  arch.  In  all,  about  fifteen  pieces  had  been  removed 
from  tlie  riglit  orbit  or  conjunctival  cul-de-sac,  and  one  from  the 
left.  Two  pieces  which  she  had  preserved  measured  nearly  four 
centimeters  in  length  and  twenty-seven  millimeters  in  breadth. 

The  following  year,  she  having  declared  on  two  different 
occasions  that  she  had  suddenly  lost  sight,  she  was  taken  to  con- 
sult another  colleague,  who  suspected  that  the  case  was  one  of 
simulation  and  made  a  diagnosis  of  intermittent  amaurosis,  sine 
DHtteria,  of  hysterical  origin.  She  was  treated  with  the  continuous 
current,  and  given  bromide  of  potassium,  and  ordered  hydro- 
therapy. At  the  end  of  several  days'  time  the  vision  again  became 
normal.  She  now  asserted  that  the  sight  of  the  left  eye  had  been 
lost  six  months  before,  as  a  result  of  a  violent  inflammation 
brought  on  by  the  presence  and  removal  of  several  fragments  of 


28  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

glass.  For  about  six  weeks'  time  she  suffered  no  pain  on  this  side, 
believing  that  all  of  the  pieces  of  glass  had  been  removed.  From 
the  right  side,  a  small  piece  had  been  extracted  six  weeks  before. 
During  the  succeeding  two  days  blood,  like  the  pains,  appeared 
intermittently  during  certain  movements  of  the  eyeball.  In  spite 
of  this  state  of  affairs  she  had  continued  to  work  in  two  different 
houses,  courageously  enduring  the  pains  (as  she  said),  and  only 
going  to  bed  a  few  hours  before  the  expulsion  of  the  fragments. 

The  skin  of  the  eyelids  and  of  the  periorbital  region  on  the 
left  side,  when  carefully  cleansed,  failed  to  present  any  trace  of  a 
scar.  One  centimeter  from  the  free  border  of  the  right  lower  eyelid 
were  two  cicatrices  each  one  centimeter  long  and  one  millimeter 
wide,  these  corresponding  in  position  vrith  a  fistulous  wound  of  the 
conjunctiva.  The  conjunctiva  and  the  cornea  of  the  left  eye  were 
normal.  The  pupil  was  dilated  and  at  its  lower  internal  part  there 
was  a  small  posterior  synechia.  The  iris  was  immobile.  Ophthal- 
moscopic examination  was  negative.  Tlie  ocular  conjunctiva  of  the 
right  eye  was  hyperemic,  especially  in  its  nasal  half.  Three  milli- 
meters from  the  cornea,  situated  between  the  internal  and  the  in- 
ferior rectus  muscles,  there  was  a  wound  of  the  mucous  membrane, 
about  fifteen  millimeters  long,  which  lan  obliquely  downward  and 
outward,  this  being  closed  by  a  fibrinous  clot.  In  the  lower  con- 
junctival cul-de-sac  there  was  some  bloodstained  mucus.  The 
cornea,  the  iris,  and  the  sclera  failed  to  present  any  lesion  whatso- 
ever. 

The  movements  of  the  eyeball  were  very  painful  in  most 
directions,  they  becoming  almost  impossible  when  the  patient  made 
endeavors  to  look  inward.  There  was  no  displacement  of  the 
eye.  The  eyelids  could  be  veiy  easily  opened,  and,  on  palpation 
of  their  surface,  nothing  could  be  discovered.  A  complete  exami- 
nation of  the  conjunctival  cul-de-sacs,  of  the  semilunar  fold,  and 
of  the  caruncle,  gave  negative  results. 

A  No.  1  Bowman  probe  was  carefully  introduced  into  the 
fistulous  wound,  and  an  examination  in  different  directions  was 
made  without  obtaining  the  sensation  of  a  foreign  body.  Cold 
compresses  were  applied  and  results  were  awaited.  The  next  day 
the  patient  exhibited  a  small,  quite  blunt  piece  of  glass  which 
.she  said  had  spontaneously  left  the  wound  without  occasioning 
great  pain.     At  this  visit  the  blood  continued  to  ooze,  the  con- 


Traumatic  Lesions  of  the  Ocular  Adnexa.  29 

junctiva  was  more  injected,  and  the  upper  eyelid  was  somewhat 
swelled.  The  patient  stated  tliat  she  felt  another  fragment  which 
was  ready  to  be  extruded.  A  few  exploratory  attempts  with  the 
Bowman  probe  were  made  without  avail.  Two  days  later  the 
foreign  material — a  piece  of  glass — was  discovered  and  was  readily 
extracted  by  the  aid  of  a  small  strabismus-hook.  Every  three  or 
four  days  after  this  there  were  fui'ther  disengagements  of  pieces 
of  glass,  these  at  times  appearing  every  day.  Some  of  them  came 
out  spontaneously,  these  being  the  smallest  ones  and  those  that 
could  not  be  discovered  during  the  examination  even  but  a  few 
hours  before  their  expulsion.  The  other  fragments  varied  in  size 
from  four  to  eight  millimeters  in  length  and  from  four  to  five 
millimeters  in  breadth.  These  were  more  or  less  easily  removed 
with  either  a  fixation-forceps  or  a  strabismus-hook.  The  move- 
ments and  the  exit  of  these  pieces  of  glass  gave  rise  to  the  fol- 
lowing symptoms:  Pain  about  the  eye  and  in  the  orbit,  which  was 
rendered  more  severe  as  the  dimensions  of  the  bits  of  glass  were 
larger  and  their  angles  and  edges  were  more  acute;  considerable 
swelling  of  the  eyelids;  intense  conjunctival  inflammation;  and 
an  effusion  of  bloody  liquid  with  abundant  mucus.  The  cornea  re- 
mained intact.  The  pupil,  which  was  dilated  by  atropine,  showed 
the  presence  of  two  synechia*  in  its  lower  part.  Movements  of  the 
eyeball  were  impossible.     Vision  was  greatly  disturbed. 

The  patient  suffered  from  insomnia.  There  were  frequent 
attacks  of  vomiting,  the  patient  being  able  to  take  only  small 
amounts  of  bouillon. 

As  soon  as  the  piece  which  was  supposed  to  have  given  rise 
to  the  last  grouping  of  symptoms  came  out,  the  blood  stopped 
oozing,  the  conjunctival  wound  started  to  close,  the  swelling  of 
the  lids  subsided,  and  the  inflammation  of  the  mucous  membrane 
ceased.  After  this  the  patient  was  able  to  sleep  and  she  no  longer 
vomited. 

A  few  weeks  later  she  became  delirious,  so  frightening  the 
person  who  was  watching  her  that  the  author  was  called  for  in 
all  haste.  It  soon  becoming  evident  that  a  case  of  simulation  was 
being  dealt  with,  a  threat  of  the  hospital  and  of  the  use  of  a  strait- 
jacket  put  an  end  to  the  crisis.  On  that  very  night  she  com- 
plained of  violent  pains,  caused,  she  said,  by  the  presence  of  several 
pieces  of  glass  which  she  felt  were  deeply  seated  in  the  back  part 


30  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

of  her  eye.  Another  examination  failed  to  give  anything  but  nega- 
tive results.  The  following  day  was  marked  by  the  appearance  of 
violent  pains.  The  lids  of  the  eyeball  were  the  seat  of  disquieting 
inflammatory  symptoms.  At  this  juncture  the  author  decided  to 
look  for  any  fragments  and  if  possible  to  extract  them.  Taking 
as  a  starting-point  the  fistulous  wound,  the  subconjunctival  tissue 
between  the  external  and  the  inferior  rectus  muscles  was  incised 
and  two  fragments  of  glass  were  extracted  without  much  difficulty. 
One  of  the  pieces  was  triangular  in  shape  and  each  was  greater 
than  one  centimeter  in  length.  This  laborious  extraction  was  fol- 
lowed by  a  comparatively  long  period  of  freedom  from  inflamma- 
tory symptoms  and  the  patient  ceased  to  sufl'er;  but,  at  the  end 
of  several  days'  time,  however,  she  again  complained  of  the  pres- 
ence of  another  fragment.  Still  many  other  pieces,  making  a  total 
of  twenty-two,  were  removed.  At  last  she  was  told  that  there 
were  doubts  of  her  good  faitli,  and  she  was  made  to  understand 
that  she  could  no  longer  depend  upon  obtaining  the  author's  pro- 
fessional services. 

In  the  hope  that  she  would  be  made  to  confess  her  deceit, 
she  was  asked,  nevertheless,  to  return,  with  her  family,  after  an 
interval  of  about  six  weeks'  time.  Upon  her  return  it  was  found 
that  the  fistulous  wound  of  the  conjunctiva  was  closed.  At  this 
visit  she  persisted  she  had  lost  the  vision  of  the  left  eye.  By  the 
employment  of  suitable  methods  for  determining  simulation  it  was 
quickly  ascertained  that  both  eyes  had  about  four-fifths  visual 
acuity.  It  was  very  difficult,  however,  in  spite  of  this  evidence, 
to  make  her  assert  that  she  saw  as  well  with  her  left  eye  as 
she  did  with  her  right  one;  and  too  many  motives  kept  her  from 
confessing  the  voluntary  introduction  of  the  fragments  of  glass. 

In  this  case  the  eye  remained  practically  intact.  It  is  easy 
to  understand,  however,  how  the  irritation  produced  by  the  tem- 
porary presence  of  the  fragments  of  glass  in  the  anterior  part  of 
the  orbital  cavity  or  in  the  fistulous  wound  of  the  conjunctiva 
did  not  produce  serious  lesions  of  the  ocular  envelopes.  Only  twice 
was  an  incision  found  to  be  necessary  to  remove  the  pieces  from 
deeper  positions,  these  interferences  always  being  endured  by  the 
patient,  Avho  each  time  refused  an  anesthetic. 

From  the  first  day  that  I  interrogated  this  patient  specula- 
tions arose  in  my  mind  as  to  her  being  a  malingerer.    I  constantly 


Traumatic  Lesions  of  the  Ocular  Adnexa.  3X 

asked  myself  liow  all  of  these  glass  splinters  could  have  penetrated 
into  the  orbit  at  one  period  of  her  life-time.  Many  reasons,  more- 
over, made  me  suspect  the  veracity  of  the  assertions  of  the  patient : 
for  example,  the  dift'erent  versions  she  gave  of  the  nature  of  the 
accidents  and  the  evident  motives  which  she  might  have  had  for 
simulating. 

The  most  careful  examination  of  the  orbito-palpebral  region 
showed  only  two  small  cicatrices  that  were  situated  on  the  sur- 
face of  the  lower  lid,  tliese  being  in  direct  relation  with  a  fistulous 
wound  of  the  conjunctiva  through  which  it  would  have  been  im- 
possible for  the  two  large  fragments — that  the  patient  showed  me 
and  for  some  of  the  other  pieces  which  I  did  not  see — to  have 
entered  without  having  produced  a  greater  number  of  wounds,  or 
at  least  without  having  made  more  extensive  lacerations.  More- 
over, any  splintering  of  the  fragments  against  the  orbital  walls 
could  not  have  taken  place  without  having  given  rise  to  discover- 
able lesions. 

The  lacrymal  gland  and  the  lacrymal  sac  are  protected 
hy  tlie  projections  of  the  orbital  and  the  nasal  edges  of  the 
orbit  and  quite  readily  escape  injuries  from  contusions 
and  direct  wounds.  Nevertheless,  the  lacrymal  gland  has 
been  penetrated  by  foreign  bodies  and  projectiles.  Pene- 
trating wounds  of  the  orbit  and  of  the  external  parts  of  the 
upper  lid  may  also  reach  the  lacrymal  gland,  such  injuries 
to  the  gland  being  exceptionally  followed  by  the  formation 
of  fistula.  They  are,  however,  of  no  serious  consequence, 
unless  there  has  been  an  infection  of  the  glandular  tissue 
or  of  the  surrounding  conjunctiva. 

Notwithstanding  the  complete  or  the  incomplete  de- 
struction of  the  gland,  lubrication  of  the  anterior  surface 
of  the  eyeball  is  sufficiently  assured  by  the  secretion  from 
the  accessory  glands  (the  palpebral  portion  of  the  lacrymal 
gland  and  the  glands  of  Krause).  This  fortunate  result, 
however,  is  not  seen  in  cases  in  which  the  lacrymal  sac  and 
the  nasal  duct  have  been  involved  or  when  such  cases  are 


32  Injuries  to  the  Eyr  hi  their  Medico-legal  Aspect. 

complicated  by  fractures  in  this  region.  Serious  disturb- 
ance with  the  excretion  of  tears  is  caused  by  a  deviation 
and  a  contraction,  and  sometimes  by  an  obliteration,  of  the 
excretory  ducts:  lesions  that  necessitate  weeks  and  even 
months  of  treatment  before  any  useful  degree  of  recovery 
can  be  assured. 


PART  SECOND. 
TRAUMATIC  LESIONS   OF  THE  EYEBALL. 


CHAPTER  I. 

Cornea.^  1 

Traumatic  lesions  of  the  cornea  produced  by  pointed, 
edged,  and  blunt  instruments;  by  foreign  bodies;  or  by 
chemical  or  burning  substances  are  the  most  frequent 
forms  of  injuries  of  the  eye  that  are  seen.  They  may  in- 
volve a  part  or  may  include  the  entire  thickness  of  the  cor- 
neal membrane,  or  tJiey  may  open  the  anterior  chamber 
and  be  complicated  ])y  disturbances  of  the  deeper  parts 
of  the  eyeball  (the  iris,  the  crystalline  lens,  the  vitreous 
body,  the  retina,  and  the  choroid).  We  shall  consider  here 
the  injuries  that  are  limited  to  the  cornea  alone. 

(a)  wounds  and  contusions  of  the  cornea. 

Punctures,  scrapings,  and  small  linear  sections  made 
with  clean,  pointed  or  cutting  instruments  such  as  scissors, 
knives,  awls,  needles,  or  pieces  of  glass,  etc.,  always  heal 
very  rapidly  and  often  without  leaving  any  trace  that  is 
appreciable  to  the  naked  eye.  There  may  be,  however, 
recurrent  attacks  of  pain  (traumatic  keratalgia),  as  the  re- 
sult of  superficial  excoriations,  such  as  are  made  by  the 
teeth  of  metallic  combs  (Arlt,"-  Grandclement^^),  that  may 
recur  from  month  to  month  or  even  from  year  to  year. 
Slight  astigmatism  is  also  of  frequent  occurrence,  but  in 

3  (83) 


34  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

time  becomes  less.  Such  disturbances  are  not,  however,  to 
be  considered  as  permanent. 

Pricking  of  the  cornea  by  a  metallic  pen  is  relatively 
a  quite  frequent  accident  among  children,  and  is  very 
dangerous  not  only  on  account  of  an  indelible  form  of  tat- 
tooing that  is  produced  by  infiltration  of  the  ink  into  the 
layers  of  the  cornea,  but  also  more  greatly  on  account  of 
the  frequency  of  the  occurrence  of  a  consecutive  form  of 
keratitis  of  suppurative  type,  with  iritis. 

Still  more  serious  complications,  such  as  the  loss  of 
an  eye  by  panophthalmitis,  are  to  be  feared.  The  same 
is  true  if  the  wound  has  been  infected  by  the  offending 
body  or  by  the  secretions  of  the  conjunctiva,  the  lids,  or 
the  lacrymal  apparatus,'*  this  being  especially  so  if  the  pa- 
tient is  old,  poorly  nourished,  and  unclean,  or  if  he  is 
debilitated  by  such  conditions  as  diabetes  and  albuminuria. 

It  is  without  doubt  dependent  on  the  dyscrasia  which 
is  produced  by  the  puerperium  and  lactation  that  the  pecul- 
iar severity  of  scratches  of  the  cornea  by  the  nails  of  in- 
fants at  the  breast  must  be  attributed.  The  medical  expert 
must  therefore  distinguish  the  portion  of  the  condition 
that  is  due  to  the  accident  from  that  which  may  have  been 
dependent  on  the  previous  condition  of  the  patient. 

A  deep  irregular  wound,  even  when  it  is  not  compli- 
cated by  suppuration,  heals  slowly  (in  the  course  of  several 
weeks'  time),  and  leaves  a  more  or  less  opaque  and  ex- 
tensive cicatrix,  which  materially  diminishes  the  visual 
acuity,  particularly  when  the  scar  is  situated  in  front  of 
the  pupil,  or  when  it  has  produced  an  irregular  curvature 
in  the  cornea.  The  practical  effects  of  such  a  central 
opacity  will  depend  upon  the  employment  of  the  patient. 
For  example,  it  would  be  much  more  serious  in  the  case 
of  a  jeweler  or  of  an  accouutaut  than  it  would  be  for  a 


Traumatic  Lesions  of  the  Eyeball.  35 

common  laborer.  However^  too  unfavorable  a  prognosis 
must  not  be  made,  as  these  types  of  opacities  have  a  tend- 
ency to  clear,  especially  in  very  young  subjects. 

For  varying  periods  of  time  this  cicatricial  tissue  is 
less  resistant  to  exterior  violence  and  offers  a  much  weak- 
ened barrier  to  the  entrance  of  infectious  material;  and 
there  is  always  the  possibility  of  later  complications,  such 
as  staphyloma  and  perforation  of  the  cornea  following  an 
attack  of  panophthalmitis. 

Contused  wounds  caused  by  pieces  of  stone  are  serious, 
as  they  are  always  likely  to  suppurate  even  under  the  most 
favorable  circumstances,  the  necrotic  tissues  making  good 
culture-media  and  thus  encouraging  the  growth  of  organ- 
isms. 

Penetrating,  V-shaped,  and  circular  wounds,  especially 
those  that  are  situated  at  the  periphery  of  the  corneal 
membrane,  are  usually  complicated  by  attachments  of  the 
iris  to  the  posterior  surface  of  the  cornea  (anterior  syne- 
chia) or  by  prolapse  and  incarceration  of  the  iris  in  the 
wound.  Sometimes  these  complications  give  rise  to  serious 
results,  such  as  adherent  leucoma,  secondary  glaucoma, 
and  iridochoroiditis,  followed  by  atrophy  of  the  eyeball. 

Prognosis  in  all  such  cases  should  in  consequence  be 
very  reserved.  In  fact,  besides  delaying  the  cicatrization 
of  the  wound  and  producing  a  deformity  or  a  displace- 
ment of  the  iris  or  an  occlusion  of  the  pupil,  the  position 
of  the  incarceration  of  the  iris  may  become  the  starting- 
point  of  inflammatory  complications  which  may  necessi- 
tate enucleation  and  even  menace  the  functional  and  the 
anatomical  integrity  of  the  opposite  eye.  On  the  other 
hand,  in  adherent  leucomata  or  in  partial  staphylomata  it 
is  possible,  by  such  an  operative  procedure  as  an  iridectomy, 
to  restore  a  certain  degree  of  vision  to  the  organ. 


36  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

Among  the  rare  complications  of  wounds  of  the  cor- 
nea must  be  mentioned  the  establishment  of  a  permanent 
corneal  fistula  which,  from  the  presence  of  infectious  germs, 
may  expose  the  eye  to  suppuration,  and  even  offer  the 
possibility  of  the  development  of  a  fatal  form  of  tetanus. 
Pollock  has  seen  death  occur  from  such  a  complication 
caused  by  a  cut  in  the  cornea  following  a  stroke  from  the 
lash  of  a  whip.  A  similar  fatal  termination  has  also  fol- 
lowed an  injury  from  a  piece  of  steel. ^^ 

Finally,  in  penetrating  wounds  of  the  cornea  one  or 
more  of  the  eyelashes  may  be  carried  into  the  anterior 
chamber,  or,  more  rarely,  they  may  pass  into  the  vitreous 
humor,  where  they  may  act  as  septic  foreign  bodies;  or  they 
may  produce  simple  or  dermoid  cysts  of  the  iris  (Roth- 
mund, Masse). 

The  cornea,  thanks  to  its  elasticity,  is  not  easily 
ruptured,  while  its  contusion  through  the  thickness  of  the 
instinctively-closed  eyelids  ordinarily  has  no  ill  conse- 
quences beyond  the  lesions  to  the  deeper  parts  (crystalline 
lens,  choroid,  retina,  etc.),  which  are  the  results  of  a  violent 
commotion  given  to  the  globe  itself. 

Simple  ruptures  confined  to  the  cornea  are  very  rare, 
for  they  usually  extend  beyond  the  sclero-corneal  junction. 
These  will  be  considered  later  on. 

Slight  contusions  of  the  cornea  that  are  due  to  the 
direct  action  of  blunt  particles  of  wood  or  metal  produce 
circumscribed  losses  of  epithelium,  though  they  may,  if  the 
loss  of  substance  is  not  infected  by  pathogenic  organisms, 
heal  without  leaving  a  trace.  When,  however,  the  trauma- 
tism is  great  or  if  the  secretions  of  the  conjunctiva  and  the 
lacrymal  passages  are  septic,  the  abraded  surfaces  may  be- 
come infiltrated  and  a  necrosis  of  the  corneal  tissue  may 
pass  on  to  perforation,  with  the  result  of  large  adherent 


Trauhuitiv  Lesions  of  the  Eyehall.  37 

leucomata  or  of  broad  staphylomata,  and  at  times  a  pan- 
ophthalmitis, with  conseqnent  loss  of  sight. 

(]{)  rOKElGN  BODIES  IN  THE  CORNEA. 

Foreign  Ijodies  situated  in  ilie  cornea  are  seen  daily 
in  industrial  centers.  The  most  commonly  found  objects 
are  cinders  and  small  irregular  fragments  of  steel  that  have 
been  chipped  from  badly  tempered  and  old  tools  or  have 
been  broken  from  masses  of  iron  or  steel.  Blacksmiths, 
edgers,  mill-wrights,  mechanics,  and  locomotive  firemen  are 
the  most  exposed  classes  of  subjects.  Those  who  work  with 
sheet-iron,  copper,  and  tin  are,  on  account  of  the  mallea- 
bility of  these  metals,  less  liable  to  injury.  Knife-sharp- 
eners and  grindstone-workers,  especially  if  they  are  not 
protected  by  proper  spectacles,^"  are  very  often  subjected 
to  injuries  of  this  nature,  not  only  by  metallic  particles,  but 
by  pieces  of  sandstone  or  emery. 

Machine-tools,  lathes,  and  planing  machines,  in  par- 
ticular, throw  off  fragments  of  hard  and  brittle  metals, 
such  as  cast-iron  and  bronze.  By  some  it  is  deemed  justi- 
fiable to  place  the  responsibility  upon  the  owner,  if  the  tools 
are  liadly  tempered  and  consequently  are  dangerous  to  use. 

Small  metallic  particles  imbedded  in  the  cornea  may 
cause  so  little  annoyance  and  reaction  that  the  patient  may 
be  unaware  of  their  presence.  In  fact,  a  number  of  cases 
have  been  reported  (Velpeau,  Grand,  Yvert,  Knapp,  Mag- 
nus, etc.)  in  which  aseptic  bits  of  steel  and  glass  have  been 
encysted  for  months  and  years. 

As  a  rule,  if  the  foreign  body  is  at  once  removed  in 
such  cases,  the  patient  can  return  to  A\ork  in  one  or  two 
days'  time,  but  if  there  be  any  neglect  of  the  injury  the  eyes 
may  be  incapacitated  from  use  for  a  period  of  several  weeks. 


/. 


38  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

On  the  contrary,  the  gravity  of  the  accident  is  rendered  far 
different  if  the  foreign  body  has  been  deeply  seated  or  if  it 
has  severely  contused  the  corneal  membrane;  and,  above 
all,  if  the  foreign  material  has  been  charged  with  septic 
organic  matter.  In  a  work  published  in  1888^^  the  author 
noted  such  types  of  serious  complications  in  five  out  of  one 
hundred  and  eighty  cases  of  foreign  body  in  the  cornea. 
In  this  grouping  infectious  keratitis,  followed  by  loss  of 
the  eye,  appeared  once;  almost  total  staphyloma  following 
an  infectious  form  of  keratitis  was  seen  once;  while  dense 
cicatricial  leucomata,  with  reduction  of  visual  acuity  to 
one-half  of  normal,  were  found  in  three  instances. 

A  point  to  be  noted  is  that  these  complicated  cases 
were  all  seen  in  "edgers."  These  men,  by  means  of  a 
hammer  and  a  chisel,  remove  the  narrow  projections  which 
are  formed  on  the  surfaces  of  molded  casts,  these  pieces 
being  usually  covered  with  a  sand  mixture,  which  is  com- 
posed of  clay  and  fine  charcoal,  mixed  with  various  excreta. 
In  such  cases  the  corneal  wound  becomes  quickly  infected, 
and,  as  in  Stromeyer's  experiments,  severe  ulcerative  kera- 
titis Mdth  hypopyon,  followed  by  rapid  destruction  of  the 
substance  of  the  cornea,  generally  appears.  The  form  and 
the  nature  of  the  foreign  body  are  also  of  considerable  im- 
portance. Irregular  fragments  of  stone  or  metal  with 
obtuse  angles  contuses  the  cornea  much  more  than  sharply 
edged  and  polished  particles  of  steel  or  iron,  the  contused 
wound  that  is  produced  by  the  former  type  of  agents  retain- 
ing any  septic  material  much  better  than  the  form  of  injury 
that  is  produced  by  the  latter. 

Finally,  the  danger  of  infection  of  a  corneal  wound  is 
much  increased  by  the  presence  of  a  dacryocystitis  and  a 
muco-purulent  conjunctivitis,  especially  in  alcoholic  and 
senile  subjects.     As  early  as   1873  tbo  author^^  showed 


Traumatic  Lesions  of  the  Eyeball.  39 

the  marked  influence  that  is  exercised  upon  the  cicatriza- 
tion of  corneal  wounds  by  diseases  of  the  conjunctiva  and 
the  general  condition  of  the  patient. 


(c)    BUKNS    OF   THE    COENEA 


39 


It  has  been  noted  in  a  previous  chapter  that  in  burns 
of  the  face  the  conjunctiva,  the  cornea,  the  sclera,  and 
the  eyelids  are  frequently  involved  in  association.  The 
cornea,  however,  may  be  alone  injured  by  incandescent 
bodies,  while  caustic  fluids  nearly  always  extend  their  action 
to  the  oculo-palpebral  conjunctiva. 

The  prognosis  of  isolated  burns  of  the  cornea  varies 
according  to  their  extent  and  in  accordance  with  the  nature 
of  the  substance  from  simple  desquamation  of  the  epithe- 
lium (burns  of  the  first  degree)  to  more  or  less  extensive 
ulceration  and  necrosis  with  perforation  and  loss  of  the  eye- 
ball. It  is  best  to  avoid  giving  a  favorable  prognosis  too 
quickly.  Eyes  that  are  apparently  but  slightly  injured  may 
be  lost  in  several  weeks'  time,  the  lesions  often  being  deeper 
than  the  early  symptoms  have  apparently  indicated.  On  the 
contrary,  it  is  surprising  at  times  to  find  a  return  of  the 
cornea  to  its  normal  condition  in  cases  in  which  the  injury 
seemed  to  have  been  very  serious.  Certainty  of  opinion  as 
to  the  degree  of  corneal  burns  is,  in  fact,  a  difficult  task.  If, 
however,  the  cornea  presents  but  a  slight  amount  of  loss  of 
epithelium,  or  evidences  but  a  thin  gray  opacity,  through 
which  the  pupillary  margin  of  the  iris  can  be  seen,  a  cure 
may  be  generally  expected  by  treatment  in  a  few  weeks' 
time. 

Acids  (particularly  sulphuric  acid),  boiling  water,  and 
ignited  gases  usually  give  rise  to  marked  disturbances,  such 
as  necrosis  of  the  cornea,  atrophy  of  the  eyeball,  adherent 


40  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

leucomata  followed  by  glaucoma  and  sympathetic  ophthal- 
mia,— frequently  leading  to  absolute  loss  of  vision. 

Among  the  superficial  and  the  benign  forms  of  burns 
are  to  be  included  those  which  are  produced  by  particles  of 
phosphorus,  grains  of  burning  powder,  sparks,  and  incan- 
descent metallic  chips  from  slag  or  those  that  are  thrown 
oif  from  slag,  blacksmiths'  hammers,  and  heated  metal. 
In  none  of  the  cases  of  these  types  that  have  been  ob- 
served by  the  author  has  there  been  any  tendency  to 
severe  inflammation  (keratitis  with  hypopyon)  such  as 
Terrier  and  Latour  Saint- Ygest  have  noted  as  appearing 
after  injuries  from  ignited  coke  and  coal.**^ 

Incandescent  or  molten  metals  cause  both  superficial 
and  deep  burns,  these  being  in  accordance  with  the  nature 
of  the  metals  and  in  direct  relation  with  their  dilferences 
of  points  of  fusion.  Brass,  iron,  steel,  and  copper — which 
fuse  at  much  higher  temperatures  than  antimony,  lead,  zinc, 
and  tin — Inirn  more  deeph^ 

When  the  burn  is  superficial  the  corneal  epithelium 
is  raised  and  forms  a  small,  whitish  pellicle,  which  resem- 
bles coagulated  albumin  or  the  white  of  an  egg.*^  This 
appearance  may  be  mistaken  as  an  expression  of  a  serious 
lesion,  but  in  the  superficial  form  of  injury  the  membrane 
is  easily  removed  by  slight  pressure.  In  addition,  there  is 
hyperemia  of  the  conjunctiva,  with  photophobia  and  pain. 
Eecovery  takes  place  in  a  few  days'  time. 

Deep  burns  by  metals  in  the  state  of  high  fusion  con- 
vert the  injured  portions  of  the  cornea  into  grayish-yellow 
eschars,  the  sloughing  of  which  is  almost  certain  to  be  fol- 
lowed by  perforation  of  the  eyeball  with  panophthalmitis. 

On  account  of  the  continual  employment  of  slacked 
lime  in  mortar,  cement,  etc.,  burns  caused  by  this  sub- 
stance are  of  very  frequent  occurrence. 


Traumatic  Ltsions  of  the  Eyeball.  41 

More  rarely,  particles  of  quick-lime  are  thrown  into 
the  eyes  and  either  destroy  small  portions  of  the  cornea  or 
convert  the  entire  membrane  into  a  pnlpified  mass.'*- 

The  prominent  feature  of  burns  by  slaked  lime  is  a 
calcareous  infiltration  of  the  cornea^,  Avith  destruction  of  its 
layers  to  depths  that  vary  with  the  intensity  of  the  injury. 
Only  the  very  slight  amounts  of  deposition  are  reabsorbed 
or  are  removed  by  separation  of  the  superficial  eschar.  In 
the  majority  of  cases  an  intense  degree  of  inflammation 
persists  for  a  period  of  many  weeks,  and  in  some  instances, 
corneal  vascularization,  which  is  necessary  for  the  repair 
of  the  membrane,  may  remain  in  the  form  of  a  pannus. 
Extensive  and  deep  destruction  of  the  corneal  tissues  may 
menace  not  only  the  cornea  itself,  but  may  also  affect  the 
entire  organ. 

Burns  by  lime  have  an  important  place  among  the 
lists  of  different  types  of  traumatism  to  which  workmen 
endeavor  to  attribute  a  lowering  of  visual  acuity  that  is 
largely  duo  to  other  causes  and  for  which  they  lay  claim 
to  heavy  damages.  The  following  re])ort  is  one  that  has 
been  made  by  the  author  to  an  insurance  company,  in  a 
case  of  this  character: — 

Case  VI  (personal  and  unpublished). — Burns  of  both  cor- 
nea by  lime-dust.     ]Medieo-leoal  report. 

I  have  the  honor  of  submitting  to  the  company  the  follow- 
ing report  upon  the  visual  function  of  Mr.  H.,  aged  Go  years,  a 
Avorkuian  in  the  sugar-refinery  of  X,  who  is  said  to  have  gotten 
lime-dust  in  both  eyes  on  the  night  of  October  25,  189  -. 

Previous  History. — As  H.  has  varied  considerably  in  his 
responses,  too  much  credence  cannot  be  placed  in  his  statements 
about  the  accident  and  its  consequences.  However,  from  his  vari- 
ous declarations,  it  appears  that  he  was  injured  during  the  night, 
and  continued  to  work  until  daybreak;  that  he  has  been  at  the 
hospital  in  X   for  a  period  of  three  weeks,  for  treatment  of  the 


42  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

right  eye;  and  that  the  vision  of  the  left  eye  was  reduced  to  per- 
ception of  light  before  the  accident. 

Present  Condition. — The  patient  was  seen  on  the  26th  of 
last  December  and  again  to-day,  Januaiy  3d.  When  first  seen  he 
had  the  posture  of  a  blind  man,  was  led  by  the  hand,  and  was  ap- 
parently unable  to  walk  alone.  Careful  examination  has  shown 
that  the  sight  of  the  left  eye  is  completely  abolished.  After  de- 
claring at  first  that  he  had  only  an  uncertain  perception  of  light, 
he  finally  has  been  able  to  see  to  count  fingers  at  a  distance  of 
thirty  centimeters  without  difficulty.  Examination  of  tlie  visual 
field  has  been  exceedingly  difficult,  and  the  confused  replies  of  the 
patient  have  not  permitted  me  to  determine  its  limits. 

Examination  of  the  left  eye  shows  that  there  is  a  slight  vas- 
cularization of  the  oculo-palpebi'al  conjunctiva,  without  any  appar- 
ent secretion.  No  trace  of  a  cicatrix  nor  of  any  adhesions  in  the 
cul-de-sac,  such  as  are  usually  found  in  severe  burns  by  caustic 
substances,  can  be  determined.  The  anterior  segment  of  the  eye- 
ball is  destroyed.  This  old  lesion  is  probably  the  result  of  an  in- 
tense degree  of  corneal  inflammation  which  has  invaded  sue- 
cessively  the  deeper  parts  of  the  eye  (iris,  etc.).  Whatever  it  may 
have  been,  the  atrophied  eyeball  is  not  at  present  the  seat  of  any 
irritative  processes.  Careful  palpation  fails  to  reveal  any  painful 
points.  The  patient  states  tliat  he  has  never  had  pain  in  either 
eye  or  in  the  surrounding  parts. 

After  the  instillation  of  several  drops  of  atropine  into  the 
conjunctival  cnl-de-sac  of  the  right  eye  in  order  to  study  the  con- 
dition of  the  iris  and  the  deeper  parts  of  the  organ,  the  following 
lesions  were  found:  Toward  tlie  outer  edge  of  the  eyebrow  is  a 
cicatrix  that  is  tattooed  in  black,  which,  like  a  similar  scar  that  is 
situated  at  the  root  of  the  nose,  is  superficial  and  non-adherent, 
and  has  no  connection  with  the  present  accident.  There  is  a  slight 
injection  of  the  oculo-palpebral  conjunctiva,  without  any  catarrhal 
secretion.  The  center  of  the  cornea  is  the  seat  of  a  superficial 
opacity,  while  a  smaller  one  is  situated  in  the  periphery  of  the 
membrane.  These  opacities  are  the  results  of  an  inflammation  of 
the  cornea  which  are,  perhaps,  traumatic  in  nature  (that  is  to  say, 
are  due  to  the  action  of  lime-dust).  The  neighboring  conjunctiva 
and  the  peripheral  parts  of  the  cornea  are  apparently  unaffected. 
The  limited  and  the  superficial  characters  of  the  burn  are  in  con- 
trast with  the  signs  of  previous  inflammation  of  the  iris,  the  traces 


Traumatic  Lesions  of  the  Eyeball.  43 

of  which  are  to  be  seen  in  the  form  of  a  synechia  at  the  external 
jjupillary  margin.  In  addition,  the  pupil  is  irregular;  the  iris  is 
slightly  discolored  and  it  reacts  very  sluggishly  to  light-stimulus 
and  to  atropine.  The  media  and  the  deeper  parts  of  the  eye  are 
quite  difficult  to  examine,  on  account  of  the  central  opacity  of  the 
cornea;  they  apparently,  however,  fail  to  present  any  pathological 
alterations.  The  movements  of  the  eye  are  free  in  every  direction. 
There  does  not  seem  to  be  any  strabismus. 

The  following  conclusions  may  consequently  be  drawn: — 

1.  Vision  with  the  left  eye  is  abolished.  There  is  no  reason 
to  think  that  the  left  eye,  which  is  degenerated,  and  has  been  quiet 
until  the  present  time,  will  in  the  future  show  any  inflammatory 
symptoms  or  that  it  will  have  any  deleterious  influence  upon  its 
fellow. 

2.  The  condition  of  the  right  eye  does  not  account  for  the 
almost  complete  blindness  of  which  the  patient  complains.  The 
central  opacity  of  the  cornea  and  the  old  iritis  undoubtedly  cause  a 
considerable  disturbance  of  vision,  but  the  patient  has  certainly  a 
sufficient  degree  of  visual  acuity  to  walk  alone  during  the  day, 
and  perhaps  enough  to  undertake  coarse  work. 

3.  It  is  relatively  easy  for  the  expert  to  determine  the  vision 
of  an  injured  eye  when  the  other  eye  is  normal,  but  it  is  very 
difficult  to  obtain  any  definite  results  when  the  latter  is  or  is  stated 
to  be  blind.  It  is  likewise  exceedingly  difficult  for  him  to  cal- 
culate the  condition  of  the  eyes  previous  to  an  accident,  and  to 
estimate  the  damage  that  has  been  done  by  any  traumatism. 
In  the  present  case,  it  is  very  probable  that  the  right  eye  had 
ah-eady  been  the  seat  of  an  inflammation  of  the  iris,  perhaps  also 
of  the  cornea,  and  that,  if  the  alleged  accident  really  occurred,  the 
powdered  lime  produced  a  veiy  slight  degree  of  inflammation  of 
the  cornea  and  of  the  conjunctiva.  This  conclusion  is  justified  by 
the  character  of  the  corneal  leucoma. 

In  a  similar  case  the  author  was  associated  with  his 
colleagues  Cuignet  and  Dujardin  in  the  examination  of 
Mr.  B.  for  the  civil  court  at  Lille.  Two  years  previously 
the  patient's  left  eye  had  heen  burned  by  a  jet  of  caustic 
soda  while  he  was  fixing  a  stop-cock.  B.  claimed  that  he 
was  blind,  as  a  result  of  the  accident.    The  resume  of  the 


44  Injnrivs  to  the  Eye  in  tlitir  Medico-Uyal  Aspect. 

examiuatiou  and  the  conclusions  presented  in  the  report 
are  as  follow: — - 

Case  VII  (personal  and  uiii)iiljli;?lied). — Burn  of  the  left 
cornea  by  a  jet  of  caustic  soda.  Simulation  of  amaurosis  of  both 
eyes.     Medico-legal  report. 

Right  Eye. — Aside  from  a  scarcely  perceptible  central  opacity 
of  the  cornea,  which  is  probably  due  to  an  inflammation  A\hich  oc- 
curred during  childhood,  the  right  eye  is  absolutely  normal. 

Left  Eye. — The  conjunctiva  and  the  lids  fail  to  present  any 
evidences  of  a.  burn.  A  whitish  leucoma  occupies  the  infero- 
internal  third  of  the  cornea,  and  the  limbus  at  this  point  is 
the  seat  of  a  traumatic  pterygium.  The  rest  of  the  corneal  mem- 
brane is  (juite  transparent.  There  is  no  adhesion  between  the 
iris  and  tlie  cornea;  consequently  it  may  be  fauly  stated  that 
the  latter  was  not  perforated  as  a  result  of  the  traumatism.  The 
ii"is  does  not  show  any  trace  of  a  former  inflammation.  The  pupil 
is  circular  and  the  iris  reacts  well  to  light.  The  media  and  the 
intraocular  membranes  are  normal. 

Conclusions. — The  lesions  found  are  not  sufficient  to  cause 
the  complete  abolition  of  sight  of  which  B.  complains.  The  results 
of  the  burn  of  the  left  eye  are  serious.  The  opacity  of  one-third  of 
the  area  of  the  cornea,  with  the  flattening  of  its  surface,  gravely 
compromises  the  vision  of  this  eye,  but  is  not  sufficient  to  produce 
blindness,  nor  to  afl'ect  so  seriously  its  fellow-eye,  which  was  not 
involved  in  tlie  burn,  as  is  claimed.  "We  must  therefore  assume 
that  B., 'previous  to  the  accident,  had  a  disease  of  the  organ  of 
vision,  though  difficult,  it  is  true,  to  determine. 

"While  cases  of  amaurosis  without  lesion  have  been  seen,  how- 
ever, there  is  no  case  of  partial  burn  of  the  cornea  without  per- 
foration of  which  we  are  aware  that  has  led  to  the  total  loss  of 
sight  of  both  eyes.  A  similar  burn  in  a  healthy  eye  undoubtedly 
would  have  produced  a  considerable  degree  of  reduction  of  vision, 
but  it  would  have  never  been  so  marked  as  has  been  here  asserted; 
and,  further,  Avith  so  much  transparent  cornea  it  would  be  possible 
to  improve  it  by  making  an  artificial  pupil. 

The  experts,  while  not  ignoring  the  severity  of  the  burn  of 
tlic  left  eye,  refuse  to  consider  it  as  the  cause  of  the  patient's 
asserted  blindness. 


Traumatic  Lesions  of  the  Eyeball.  45 

Powder-burns  of  the  cornea  may  be  due  to  the  pres- 
ence of  the  carbon-grains  themselves  or  to  the  gases  that 
have  been  generated  during  the  explosion  of  the  powder. 
As  a  rule,  the  grains  form  bluish-gray  opacities,  and,  in 
proportion  to  their  number,  produce  variable  degrees  of 
disturbance  of  vision.  Sometimes  the  cornea  may  ulcerate 
and  give  rise  to  perforation.  Moreover,  laceration  may  be 
caused  by  gases  that  have  been  generated  during  mine- 
explosions.  (This  subject  will  be  again  referred  to  in  the 
chapter  on  "Injuries  to  tlie  Entire  Eyeball.") 


CHAPTEE  II. 


SCLEEA.'*^ 


Injuries  to  tlie  sclera  in  themselves  are  not  serious. 
They  are,  however,  usually  combined  with  lacerated  or  with 
incised  wounds  of  the  cornea,  and  of  the  choroid  and 
retina  (penetrating  wounds  of  the  eye).  Prognosis  in  these 
types  of  eases  is  rendered  still  more  serious  by  the  en- 
trance of  various  kinds  of  foreign  bodies. 

Exceptionally  the  sclera  is  alone  involved,  the  force 
of  the  foreign  body  being  spent  while  passing  through 
the  external  layers  of  this  covering.  Such  forms  of  in- 
juries will  not  detain  us,  as  the  healing  of  non-penetrating 
wounds  of  the  sclera,  unless  infected  or  very  extensive  and 
complicated, — as,  for  example,  by  prolapse  of  the  choroid, — 
is  very  rapid. 

Foreign  bodies  in  the  sclera  and  burns  of  the  sclerotic 
membrane  will  require  but  brief  consideration. 

Foreign  bodies  (metallic  particles,  grains  of  powder, 
small  fragments  of  glass,  etc.),  are  sometimes  imprisoned 
in  the  sclera  without  perforating  it.  Pieces  of  metal  and 
fragments  of  glass  when  superficially  situated  are  easily 
removed.  Should  the  foreign  materials  be  grains  of  pow- 
der, it  is  much  the  best,  if  they  are  very  numerous,  to 
leave  them  alone,  for  any  attempts  that  may  be  made  to 
extract  them  may  prove  to  be  more  injurious  to  the  patient 
tlian  the  results  of  any  staining  that  may  arise  from  their 
presence. 

It  has  been  previously  mentioned  that  certain  molten 
metals — such  as  brass,  iron,  and  copper,  but  particularly 
(46) 


Traumatic  Lesions  of  the  Eyeball.  47 

chemical  agents,  such  as  lime,  potash,  and  sulphuric  acid 
— do  not  limit  their  destructive  influences  to  the  con- 
junctival mucous  membrane.  As  a  rule,  the  sclera  is 
burned  and  the  eye  may  be  lost  through  phthisis,  even 
after  prolonged  courses  of  proper  treatment.  It  is  im- 
portant, therefore,  from  a  medico-legal  stand-point,  that 
the  physician,  if  he  wishes  to  avoid  any  gross  error  in  prog- 
nosis, shall  not  be  deceived  by  the  superficial  appearance 
of  the  effects  of  any  such  burns,  by  slight  inflammatory 
reaction,  and  by  the  apparent  benignity  of  the  symptoms 
that  are  found  during  the  first  few  days. 

The  most  important  traumatic  lesions  of  the  sclera  are 
the  result  of  the  action:  (1)  of  pointed  or  cutting  instru- 
ments or  the  entrance  of  foreign  bodies  [i.e.,  penetrating 
wounds] ;    (2)  of  blunt  bodies  [scleral  ruptures] . 

(a)  peneteating  wounds  of  tue  sclera. 

The  anatomical  relations  of  the  sclera  and  the  pro- 
tection that  is  afforded  it  by  the  bony  plates  which  limit 
the  orbital  cavity  are  sufficient  to  explain  the  ordinary  situa- 
tion of  ocular  wounds  near  the  cornea  and  below  and  to 
the  outer  side.  Such  wounds  generally  occur  in  soda-water 
factories,  metal-shops,  abattoirs,  machine-shops,  etc.  The 
usual  causes  are  metal  fragments,  small  pieces  of  caps, 
splinters  of  glass,  bits  of  stone,  points  of  shuttles,  knives, 
scissors,  prongs  of  forks,  awls,  bodkins,  etc. 

The  prognosis  of  a  prick  of  the  sclera,  unless  the 
wounding  agent  has  injured  the  lens  and  the  ciliary  body 
or  is  charged  with  infectious  germs,  is  favorable.  In  the 
latter  type  of  injuries  grave  complications — such  as  trau- 
matic cataract,  iridochoroiditis,  and  panophthalmitis — 
are  to  be  feared.^* 


48  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

Three  patients  with  the  minor  class  of  injury  who  were 
treated  by  the  author  recovered  without  the  slightest 
diminution  in  central  visual  acuity  and  without  any  ap- 
preciable decrease  in  the  visual  fields.  In  one  of  these  cases 
the  sclera  had  been  perforated  in  the  equatorial  region 
through  the  upper  lid,  by  the  point  of  a  large  saddler's 
awl.  There  was  a  slight  prolapse  of  the  vitreous  body. 
In  the  other  two  eases  the  scleral  pricks  were  caused  by 
ordinary  sewing-needles. 

Small,  penetrating  wounds  extending  in  meridianal 
directions,  and  those  which  are  situated  in  the  posterior 
hemisphere  of  the  eyeball,  are  said  not  to  be  as  serious 
as  was  formerly  considered.  They  heal  quite  rapidly  and 
without  any  complications  when  they  are  aseptic  and 
have  not  been  complicated  by  a  marked  loss  of  the  vitreous 
humor.  It  must  not  be  forgotten,  however,  that  there 
may  be  a  subsequent  contraction  of  the  visual  field,  fol- 
lowed by  complete  loss  of  vision,  as  the  result  of  detachment 
of  the  retina,  which  is  due  to  degeneration  of  the  vitreous 
humor  and  cicatrization  of  the  scleral  wound. 

Case  No.  8  in  de  Schuttelaere's  thesis  (penetrating 
wound  of  the  left  cornea  and  sclera;  scleral  suture;  re- 
covery with  preservation  of  some  vision)  had  a  visual 
acuity  which  equaled  one-third  of  normal  four  months 
after  the  original  accident,  Avhile,  at  the  end  of  a  year's 
time  central  vision  became  reduced  to  one-fifteenth  of 
normal  and  the  visual  field  was  abolished  throughout  more 
than  three-fourths  of  its  ordinary  extent.  The  tenth  case 
(penetrating  wound  of  the  right  sclera  caused  by  a  frag- 
ment of  steel;  conjunctival  suture;  recovery)  had  a  nor- 
mal central  acuity  of  vision  at  the  time  of  the  healing 
of  the  scleral  wound;  that  is  to  say,  one  month  after  the 
accident.    A  slight  detachment  of  the  retina  situated  at  the 


TidintKitic  Lcs'iDiix  nf  the  EychaU.  |<) 

site  of  the  wound  was  found  by  ophthalmoscopic  exami- 
nation. Xearh'  three  years  later  it  was  noticed  that  the 
retinal  detachment  had  become  markedly  increased  and 
that  the  inner  half  of  the  visual  field  was  destroyed. 

In  a  recent  case  of  penetrating  wound  of  the  sclera 
the  autho]'  sul)iiiittt'(l  tlio  following  report: — 

Case  VIII  (personal  and  nnpublished). — Penetrating  wound 
of  tlie  sclera.  Suture  of  tlie  conjunctiva.  Recovery.  Medico- 
legal repoit. 

R.,  a  27-year-old  man,  was  struck  on  the  left  eye  by  a  small 
piece  of  sheet-iron,  which  was  immediately  removed  by  one  of  his 
comrades.  The  patient  did  not  feel  any  severe  pain,  but  he  said 
that  he  saw  indistinctly  with  that  eye,  and  that  the  organ  seemed 
to  him  to  be  somewhat  smaller  than  its   fellow. 

In  the  lower  internal  part  of  the  globe  there  was  a  pene- 
trating wound  of  the  sclera  which  was  about  one  centimeter  in 
length.  It  commenced  about  three  millimeters  behind  the  edge 
of  the  cornea  and  ran  perpendicularly  to  the  cornea,  presenting 
between  its  slightly-opened  lips  a  moderately-sized  prolapse  of 
the  vitreous  humor.  The  conjunctiva  was  detached  and  formed 
a  small  Hap  with  its  base  placed  upward.  The  ophthalmoscope 
revealed  the  ])resence  of  a  hemorrhage  into  the  vitreous  humor. 

After  irrigation  of  tlie  affected  parts  with  a  1  to  5000 
strength  solution  of  corrosive  sublimate,  the  patient  was  chloro- 
formed, the  conjunctiva  at  the  lower  part  of  the  wound  was  freed, 
and  the  Haps  were  carefully  approximated  by  two  fine  carbolized- 
catgut  sutures.  During  the  operation  there  was  a  slight  loss  of 
vitreous  humor.  Irrigation  with  occlusive  dressings  saturated 
with  corrosive  sublimate  were  employed. 

In  three  days'  time  the  stitches  were  removed.  There  was 
no  inflammatory  reaction  and  the  patient  did  not  complain  of  any 
pain.     Compression  was  maintained  for  several  days. 

Fifteen  days  later  the  wound  seemed  to  be  healed  and  the 
injection  had  almost  disappeared.  The  intraocular  hemorrhage, 
however,  had  not  been  entirely  reabsorbed  and  the  eyeground  could 
be  illuminated  only  with  difficulty.  At  this  time  the  patient  could 
hardly  see  sufficiently  to  distinguish  fingers. 

4 


50  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

Fifteen  days  after  this  the  patient  could  easily  count  fingers 
at  a  distance  of  five  meters. 

Six  weeks  later  visual  acuity  had  risen  to  a  degree  that  was 
equal  to  one-third  of  normal,  tliis  improvement,  however,  being 
associated  with  a  marked  diminution  of  the  visual  field  above  and 
to  the  outer  side. 

The  condition  eight  days  following  (the  time  of  making  the 
report)  was  as  follows:  The  right  eye  was  emmetropic,  its  visual 
acuity  and  field  of  vision  being  normal.  (The  patient  stated  that 
he  had  not  had  any  trouble  from  this  eye  since  the  date  of  the 
accident.) 

At  the  site  of  the  wound  in  the  left  eye  there  was  a  slate- 
colored  and  slightly-depressed  cicatrix  which  was  adherent  to  the 
conjunctiva.  There  was  not  any  tendency  to  the  formation  of  a 
staphyloma.  The  anterior  chamber  was  of  its  usual  depth.  The 
pupil  was  normal  in  size  and  the  iris  responded  just  as  well  as  its 
fellow  of  the  opposite  side. 

The  media  were  clear.  Examination  with  the  ophthalmoscope 
showed  an  atrophic  spot  which  was  surrounded  by  pigment  situ- 
ated in  a  position  corresponding  to  that  of  the  former  solution 
of  continuity.  The  retina  internal  to  the  atrophic  spot  was  de- 
tached. The  rest  of  the  fundus  of  the  eye  failed  to  present  any- 
thing in  particular. 

The  acuity  of  vision  equaled  three-fourths  of  normal  and  the 
visual  field  was  contracted  above  and  to  the  outer  side. 

CONCLUSIONS. 

Question:  Is  the  lesion  a  definitely-characterized  traumatism? 
Did  the  patient  have  any  pre-existing  disease  of  the  eye  which 
could  have  an   influence   upon  the   present  results? 

Answer:  E.  has  a  penetrating  wound  of  the  left  sclera,  re- 
sulting from  the  impact  of  a  small  piece  of  sheet-iron.  No  trace 
of  a  congenital  affection  of  the  left  eye  or  of  an  acquired  one 
before  the  accident  has  been  found  as  the  result  of  successive  ex- 
aminations. 

Question:  What  are  the  consequences  of  this  injury?  Is  the 
present  condition  permanent?  Is  the  condition  likely  to  become 
better  or  worse? 

Answer :    Direct  vision  of  the  left  eye  is  at  present  diminished 


Traumatic  Lesions  of  the  Eyeball.  51 

by  about  one-fourth  of  what  is  considered  as  normal  and  the  visual 
field  is  markedly  contracted  in  its  upper  outer  part.  Under  these 
conditions  the  earning  capacity  of  E.  is  certainly  decreased,  but 
not  to  such  an  extent  as  to  debar  liini  from  resuming  his  former 
occupation. 

I  consider  the  present  lesions  permanent,  and  not  likely  to 
be  improved  by  the  influence  of  time  or  by  any  treatment  whatso- 
ever. 

It  is  possible,  however,  for  vision  in  this  eye  to  be  entirely 
lost  as  the  result  of  a  progressive  delac-hment  of  the  retina. 

Large,  irregular,  gaping  wounds  and  those  that  are 
complicated  by  associated  injuries  to  the  cornea,  the  iris, 
the  ciliary  body,  the  choroid,  the  retina,  or  the  lens,  and 
are  associated  with  the  destruction  of  much  of  the  con- 
tents of  the  eye,  usually  result  in  absolute  loss  of  the  in- 
jured organ  after  many  months  of  treatment  and  suffer- 
ing. In  this  respect,  deep  sclero-corneal  wounds,  which 
reach  the  subjacent  parts  and  in  particular  the  ciliary 
body,  are  of  extreme  gravity,  while  the  loss  of  the  other 
eye  from  sympathetic  disease  is  always  to  Ijo  feared. 

In  his  report  upon  "The  Surgical  Intervention  in 
Wounds  of  the  Eye  with  Penetration  of  Foreign  Bodies,"*'' 
Coppez  collected  720  cases  of  penetrating  wounds  of  the 
eyeball,  9G  of  which  were  accompanied  by  entrance  of 
foreign  materials.  In  421  cases  the  eyes  were  lost,  while 
in  52  the  patients  became  blind.  Various  types  of  sym- 
pathetic complication  were  seen  in  14  per  cent.  These 
figures  are  of  grave  prognostic  importance. 

Some  of  the  complications  of  penetrating  wounds  of 
the  sclera  are  immediate,  while  others  develop  subsequently. 

Marked  loss  of  the  vitreous  humor,  intraocular  hemor- 
rhage, incarceration  of  iris-tissue,  luxation  and  opacification 
of  the  crystalline  lens,  primary  detachment  of  the  retina, 
and  the  presence  of  foreign  bodies  in  the  interior  of  the 


52  Injuries  in  llic  Kijr  in  llicir  Miilir<i-I((i<tl  Asi)ect. 

eye  practically  constitute  the  first  class,  while  suppuration, 
iridochoroiditis,  late  or  secondary  detachment  of  the  retina, 
sympathetic  conditions,  and  l)ulbar  atrophy  belong  to  the 
second  category. 

Free  intraocular  hemorrhage  duo  to  a  wounding  of 
the  choroid  with  a  considerable  loss  of  the  vitreous  humor 
is  often  followed  by  a  detachment  of  the  choroid  and  of 
the  retina  and  l)y  violent  inflammatory  symptoms, — the 
gravity  of  which  should  not  be  underestimated.  More- 
over, any  vitreous  luunor  that  may  be  inclosed  within  the 
wound  may  become  organized  and  f<u'm  a  part  of  the  cica- 
tricial tissue,  which,  l)y  contraction,  inay,  several  weeks 
or  months  after  the  accident,  produce  detachment  of  the 
retina  at  a  point  that  is  situated  opposite  the  seat  of  injury. 
In  consequence,  in  spite  of  an  apparently  satisfactory  re- 
covery, the  medical  expert  must  not  forget  that  any  loss 
of  the  vitreous  humor,  ]io  matter  how  small,  may  produce 
a  partial  loosening  of  its  posterior  segment  (Ivanoff,  de 
Gouvea,  etc.),  as  a  result  of  which  the  patient  may  be  threat- 
ened with  retinal  detachment  and  consequent  loss  of  vision. 

Not  less  serious  are  the  consequences  of  complete  ex- 
pulsion of  the  crystalline  lens,  \\lucli  in  some  fortunate 
instances  has  been  followed,  it  is  true,  by  a  partial  and 
even  a  complete  re-establishment  of  vision  (cases  of  Dixon, 
de  Trelat,  de  Gouvea,  etc.-*").  As  a  general  rule,  however, 
total  expulsion  of  the  crystalline  lens  is  the  result  of  a 
violent  traumatism,  and  is  generally  complicated  by  a  large 
hernia  of  the  iris,  prolapse  of  the  vitreous  humor,  and  de- 
tachment of  the  retina. 

If  the  crystalline  lens  is  dislocated  into  the  vitreous 
humor,  it  may  provoke  an  attack  of  iridocyclitis  or  set 
into  action  a  series  of  glaucomatous  symptoms.  (Trau- 
matic cataract  will  be  considered  later.) 


Trdiinuitir  Lexioiis  of  the  Eyeball.  53 

Incarceration  oi'  the  ifit?,  although  niueh  less  danger- 
ous at  the  present  time  than  formerly  (thanks  to  antisep- 
sis), frequently  leads  to  the  formation  of  a  staphyloma 
wJiieh  may  l)ecojne  a  source  of  constant  irritation. 

The  prognostic  im[)orlance  of  primary  detachment  of 
the  retina  varies  in  accordance  with  its  methods  of  produc- 
tion and  hy  the  degree  of  loss  of  vitreous  liumor.  hi  the 
former  case  the  detachment  may  he  of  the  same  size  as 
tlie  wonnd  in  the  sclera  itself,  hut  in  the  latter  instance 
the  luost  frequent  result  will  he  com];)lete  loss  of  vision. 

J)eep  penetration  of  foreign  hodies  often  has  the 
most  dire  hearing  upon  the  question  of  prognosis.  (This 
complication  will  he  studied  in  the  cha])ters  on  "Foreign 
Bodies  in  the  Clioroid,"'  'Tn  tlio  Retina,"  "In  the  Crystal- 
line Lens,"  and  'Tn  the  Vitreous  Body."') 

The  late  complications  which  have  heen  enumerated 
are  nuu-li  more  serious,  since  they  compromise  not  only 
the  existence  of  the  injured  organ,  l)ut  sometimes  menace 
the  other  eye  as  Avell. 

'^I'lie  multiplicity  and  tlic  importance  of  these  ditfer- 
ent  forms  of  lesions  should  make  the  physician  who  is 
consulted  at  the  time  of  the  injury  careful  in  estimating 
the  possible  consequences  of  penetrating  wounds  of  the 
sclera.  In  any  case,  on  account  of  the  possibility  of  later 
complications,  the  medical  expert  cannot  lay  down  a  posi- 
tive judgment  before  a  lapse  of  several  months'  time. 

(13)    lUJPTURES    OF    TlIK    SCJ.EKOTIC. 

The  sclera  is  frequently  ruptured  1)y  violent  contu- 
sions of  the  eyeball  by  stabs  from  cows'  horns;  or  by  l)lunt 
bodies  such  as  the  end  of  a  cane,  an  undirella,  a  stick,  or 
a  fist;    or  l)y  falls  against  pieces  of  furniture,  etc.    In  the 


54  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

great  majority  of  such  cases  tlie  woimding  agent  inflicts  its 
blow  from  below  and  without^  where  the  bony  orbital  edge 
recedes  and  leaves  the  eyeball  partially  exposed.  The 
wonnd  generally  assumes  the  form  of  a  slender  crescent. 

This  solution  of  continuity,  which  is  most  often  in- 
direct and  due  to  contrecovp,  involves,  according  to  the 
degi"ee  of  violence  of  the  traumatism,  one  or  more  of  the 
ocular  membranes.  It  is  generally  situated  at  two  or  three 
millimeters'  distance  from  the  corneal  edge  (the  superior 
internal  part)  and  is  parallel  with  the  corneal  limbus, 
which  is  the  point  of  least  resistance:  that  is,  at  or  near 
the  canal  of  Schlemm.'*^  Moreover,  the  sclera  is  ruptured 
more  readily  in  adults  and  in  aged  subjects  in  whom  the 
ocular  coats  have  lost  the  greater  ])a]'t  (if  not  all)  of  their 
elasticity. 

On  account  of  its  laxity  the  conjunctiva  usually  re- 
mains intact,  thus  protecting  the  scleral  wound  from  in- 
fection. In  consequence,  therefore,  there  is  an  absence  of 
suppuration,  which  accounts  for  tlie  success  of  the  plan  of 
conjunctival  suturing  to  which  tlie  great  majority  of  sur- 
geons of  to-day  liave  recourse  in  cases  of  injuries  to  tbe 
sclerotic.  In  addition,  any  inflammatory  reaction  Avhich 
may  accompany  either  ruptures  or  penetrating  wounds  of 
the  sclera  is  generally  very  slight,  tliis  being  dependent, 
in  measure,  on  a  diminution  in  the  intraocular  tension. 

If  the  choroid  is  not  involved  in  the  accident,  there 
A\ill  be,  as  a  rule,  a  displacement  of  the  internal  portions 
of  the  eye  toward  the  position  of  the  solution  of  con- 
tinuity, the  equilibrium  between  tlie  intraocular  and  the 
extraoc-iilar  pressures  being  destroyed.  In  such  cases  the 
iris  and  the  choroid  form  a  bluish,  slate-colored  hernia 
which  is  situated  in  the  wound  and  which,  after  cicatriza- 
tion, may  give  rise  to  a  scleral  staphjdoma,  with  all  its 


Traumatic  Lesions  of  the  Eyeball.  55 

troublesome  consequences.  The  crystalline  lens  may  be 
pushed  toward  the  wound,  and,  on  account  of  rupture 
of  the  zone  of  Zinn,  may  become  opaque.  At  times  by 
compressing  the  iris  and  the  ciliary  body  the  dislocated 
lens  gives  rise  to  an  iridocyclitis  which  may  sympathet- 
ically menace  the  eye  of  the  other  side  (Arlt).  Although 
the  retina  may  not  be  included  in  the  wound,  yet  it  fre- 
quently becomes  detached:  a  lesion  which  is  as  serious  as 
its  laceration.  Wounds  of  the  ciliary  body  necessarily 
most  seriously  complicate  the  prognosis  of  the  condition. 

When  the  traumatism  has  been  more  violent  and  the 
sclera  and  tlie  choroid  have  been  ruptured,  the  crystalline 
lens,  with  a  part  of  the  vitreous  humor,  may  be  expelled 
at  the  same  time.  The  crystalline  lens,  however,  some- 
times remains  incarcerated  between  the  lips  of  the  wound, 
tliough  ordinarily  it  is  luxated  beneath  the  conjunctiva, 
which  forms  a  receptacle  for  it.  At  times  it  is  extruded 
through  a  rent  in  the  conjunctival  membrane.  Contrary 
to  what  happens  in  cases  of  luxation  of  the  crystalline  lens 
into  the  vitreous  body  or  into  the  anterior  chamber,  reac- 
tionary symptoms  are  not  often  complained  of,  and,  after 
absorption  of  any  intraocular  hemorrhage  and  removal  of 
the  encysted  lens,  good  vision  may  be  secured  for  several 
years  at  least*^ — provided  that  too  many  intraocular  lesions 
have  not  been  produced. 

Unfortunately,  in  the  great  majority  of  such  cases 
recovery  is  only  transient,  a  permanent  loss  of  the  visual 
function  being  the  usual  consequences  of  a  phthisis  of  the 
eyeball. 


CHAPTEE  III. 

Ieis. 

The  iris  may  be  indirectly  involved  by  contusions  of 
the  eyeball,  or  it  may  be  directly  injured  by  wounds  extend- 
ing through  the  coats  of  the  eye  from  pointed  or  cutting 
objects,  or  by  the  entrance  of  foreign  bodies. 

(a)  injueies  to  the  iris  by  contusion. 

Direct  traumatisms  to  the  eyeball  (for  example,  those 
arising  from  blows  of  fists;  strokes  from  pieces  of  wood, 
iron,  stone,  bats,  snow-balls,  or  bullets;  or  jars  from  falls 
u])on  the  periorbital  region)  may  produce  serious  lesions 
of  the  iris,  such  as  partial  or  total  detachment  of  its  tis- 
sues at  its  circumference:  known,  respectively,  as  iridodi- 
alysis  and  irideremia.  These  results  are  especially  the  case 
if  tlie  sphincter  muscle  of  the  iris-membrane  is  strongly 
contracted  at  the  time,  or  if  the  pupillary  margin  of  the  iris 
is  fixed  by  adhesions. 

Iridodialysis  (not  to  l)e  confounded  with  any  congeni- 
tal anomaly)  produces  very  little  disturbance  of  vision, 
except  when  it  is  so  large  as  to  form  an  eccentric  pupil 
tlirough  which  the  patient  can  simultaneously  see. 

The  production  of  irideremia  is  quickly  followed  by 
a  marked  dazzling  and  a  blurring  of  vision,  this  being  par- 
ticularly so  if  the  eye  is  not  normal  in  its  refractive  power. 
'I^his  generally  appears  after  the  ordinarily  present  hemor- 
rhage into  the  anterior  chamber  is  absorbed,  and  the  de- 
tached portion  of  the  iris  shrivels  aiul  becomes  degenerated. 
In  some  cases  the  torn  ]>arts  of  the  iris-tissue  mav  be  ex- 

(50) 


TraviiKitic  Lesions  of  the  Eyeball.  57 

pelled  through  a  scleral  rupture,  the  mass  either  being  alone 
or  accompanied  with  the  crystalline  lens.'*'' 

]\liu'li  inoi'c  I'arely  a  retroversion  of  the  iris,  with  a 
Ijackwai'd  luxation  (it  the  crystalline  lens,  is  found.  This 
condition  can  be  readily  distinguished  from  either  an  irido- 
dialysis  or  an  irideremia  by  an  ophthalmoscopic  examina- 
tion. In  retroversion  the  ciliary  processes  are  concealed  Ijy 
the  iris,  liut  in  iridodialysis  and  irideremia  the  processes  of 
the  ciliary  body  can  be  easily  seen  as  broad,  black  bands 
that  are  situated  against  a  red  eyeground.  Fissures  of  the 
])upillary  margin  of  the  iris"'"  and  lacerations  of  the  iris- 
substance  creating  supplementary  pupils  and  simulating 
congenital  polycoria"'^  are  comparatively  rare  conditions, 
and  are  to  be  distinguished  from  congenital  forms  of  fissures 
in  the  iris  by  the  presence  of  hyphemia,  paralytic  mydriasis, 
and  synechia.  Moreover,  colobomata  are  generally  bilateral, 
are  usually  situated  in  the  median  line  below  or  in  the  lower 
inner  quadrant,  and,  as  a  rule,  are  associated  with  other 
ocular  malformations,  such  as  coloboma  of  the  clun'oid, 
the  crystalline  lens,  or  the  eyelids;  zonular  cataract;  mi- 
crophthalmos;   harelip,  etc. 

These  various  lesions  |)roduce  more  or  less  noticeal)le 
deformities  and  give  rise  to  disturbances  of  vision  (such  as 
dazzling  and  monocular  diplopia);  but,  unless  they  extend 
to  the  deeper  structures  of  the  eye.  its  functions  are  not, 
as  a  rule,  seriously  disturljcd. 

Inflammatory  reaction  in  siuiple  traumatism  of  the 
iris  is  usually  insignificant,  and  ordinary  ■extravasation  of 
hlood  rapidly  disappears.  However,  an  attack  of  severe 
iritis  or  an  iri(h)cyclitis  may  follow  aii  iridodialysis,  or  the 
traumatism  may  have  lieen  so  ])ronounced  as  to  produce 
such  conditions  as  rupture  of  the  sclera,  luxation  and 
opacification  of  the  crystalline  lens,  laceration  of  the  cho- 


58  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

roid  and  retina,  detachment  of  the  retina,  hemorrhage  into 
the  vitreous  humor,  etc.;  so  that  in  any  given  case  a  prog- 
nosis cannot  be  offered  until  all  hemorrhagic  absorption 
has  been  completed. 

(b)  wounds  op  the  ibis  made  by  pointed  and 
cutting  instruments. 

Wounds  from  fine-pointed  instruments,  such  as 
needles,  awls,  pens,  etc.,  are  rarely  limited  to  the  tissue  of 
the  iris  itself.  In  such  cases,  however,  unless  the  wound  is 
infected,  there  is,  as  a  rule,  only  a  slight  and  temporaiT 
hyphemia  without  any  inflammatory  reaction.  Supplement- 
ary pupils  are  occasionally  formed,  as  in  a  case  that  has  been 
described  by  Fano.^" 

More  frequent  and  much  more  serious  are  wounds 
that  are  complicated  by  an  injury  to  the  crystalline  lens; 
l)ut  in  these  cases  the  seriousness  of  the  accident  depends 
upon  the  character  of  the  injury  to  the  lens. 

Such  injuries  rarely  leave  the  crystalline  lens  intact. 
The  author  has  seen  a  case  of  simple  wound  of  the  cornea 
and  tlie  iris,  in  a  medical  student,  from  a  fragment  of 
glass,  caused  by  an  explosion  of  a  glass  vessel.  Down  and 
out  from  the  pupillary  margin  there  was  a  secondary  oval 
pupil  separated  from  the  natural  pupil  by  a  bridge  of  iris- 
tissue  which  was  one-half  millimeter  broad.  One  year  later 
the  site  of  the  old  wound  of  the  cornea  was  shown  by  a 
white  line,  and  although  there  were  two  pupils  there  was  no 
dazzling  and  no  monocular  diplopia.  Tlie  media  of  the 
eye  were  transparent,  wdiile  vision  with  a  convex  cylinder 
of  three  diopters'  strength  with  its  axis  at  forty-five  degrees 
equaled  one-third  of  normal. 

The  innocent  character  of  such  wounds  is  well  shown 


Traumatic  Lesions  of  the  Eyeball.  59 

by  the  results  of  tlie  operation  for  iridectomy,  serious 
sequels,  as  a  rule,  ouly  being  present  AA'hen  the  wounding 
agents  are  septic  in  character. 

(c)    FOREIGN    BODIES    IN    THE    ANTERIOR    CHAMBER 
AND   THE    lEIS.^^ 

rarticles  of  iron,  steel,  copper,  stone,  or  glass,  grains 
of  powder,  etc.,  usually  enter  the  anterior  chamber  or  be- 
come fixed  in  the  iris  after  having  perforated  the  cornea. 
Very  rarely  they  pass  through  the  eyelids  and  tlio  sclera, 
injuring  the  crystalline  lens  during  their  passage. 

At  times  these  foreign  bodies  become  encysted  in  the 
iris-tissue  or  they  become  caught  in  the  angle  of  the  an- 
terior chamber,  and  are  tolerated  for  years  without  any 
marked  inflammatory  reaction.^*  Some  metals  are  oxidized 
and  may  undergo  dissolution.  Far  more  frequently,  how- 
ever, they  give  rise  to  a  subacute  or  a  plastic  form  of  in- 
flammation which — involving  the  cornea,  the  iris,  and  the 
ciliary  body — produces  atrophy  of  the  eye,  and  in  some 
cases,  if  enucleation  is  not  performed  or  if  the  foreign  mate- 
rial is  not  extruded  by  suppurative  processes,  a  sympathetic 
ophthalmia  may  take  place.  At  times  the  cornea  may  be 
l)ut  partially  destroyed.  In  these  forms  of  injury  an  iridec- 
tomy may  greatly  improve  vision. 

The  prognosis  in  all  such  cases,  unless  the  foreign 
l)ody  can  be  immediately  removed,  is  very  serious.  If 
the  offending  material  be  extracted,  recovery  is  generally 
l^rompt,  and  any  visual  disturbance  will,  as  a  rule,  be  quite 
insignificant. 

Case  IX  (peisonal  and  unpublished). — Foreign  body  (chip 
of  steel)  fixed  at  the  lower  external  part  of  the  left  iris.  Sup- 
purative iritis.  Extraction  of  the  foreign  material  by  an  iri- 
dectomy.    Cure. 


60  hijnrirs  to  the  Eye  hi  their  Medico-leyal  Aspect. 

On  the  twenty-seventh  of  August,  189-,  A.  C,  a  weigher,  was 
wounded  in  the  left  eye  by  a  ehip  of  steel.  Althougii  suffering 
severe  eeplialalgia.  the  patient  continued  to  work.  On  the  day  fol- 
lowing the  accident  tlic  autlioi  tdiiiid  the  foihjwing  conditions:  In- 
tense pericorneal  injection,  whicii  was  more  pronounced  in  tlie  in- 
fero-external  part  of  the  eye.  Corresponding  in  position  to  tliis  area 
of  injection  a  scarcely-visible  wound  of  the  cornea,  one  and  a  half 
millimeters  from  the  limbus.  could  be  seen.  Oblique  illumination 
revealed  the  presence  of  a  piece  of  metal  the  size  of  the  head  of  a 
pin  situated  on  the  anterior  surface  of  the  inflamed  iris  directly 
ojiposite  the  corneal  wound.  The  pujjil  was  contracted,  and  tliere 
was  a  beginning  hypopyon.  The  patient  complained  of  marked 
pain  and  photojjhobia. 

The  foreign  body,  together  with  the  portion  of  the  iris  u])on 
which  it  rested,  was  immediately  removed.  Compresses  saturated 
A\ith  a  solution  of  boric  acid  were  applied  and  atropine  was  in- 
stilled four  times  daily. 

Eight  days  later  the  iiitis  luul  yielded.  The  patient  was  dis- 
charged from  the  hospital.  Three  weeks  afterward  vision  of  the 
affected  eye,  with  the  aid  of  a  convex  spherical  lens  of  one-half  a 
diopter's  strength,  equaled  five-sixths  of  normal.  The  patient  com- 
plained of  but  a  slight  degree  of  dazzling. 

It  must  l)c'  reinc'inl)ert'(l  that  prolonged  operative  pro- 
ceditres  may  produce  a  ii'auinatit'  cataract  or  give  rise  to  a 
violent  degree  of  iritis,  reducing  vision  and  necessitating 
several  months  of  treatment. 


CHAPTER  IV. 

Choroid  axd  Ciliary  Body. 

The  anterior  juirt  oi'  the  choroid,  designated  as  the 
ciliary  region,  has  always  heen  considered  a  situation  to 
which  the  expression  of  noli  iiir  lainjcre  aptly  applies,  while 
clinical  observations  have  shown  that  wounds  of  the  ciliary 
body  and  foreign  bodies  in  it  are  among  the  most  serious 
disturbances  of  the  ocnlar  globe.  In  fact,  except  in  rare 
instances  of  encystment'"'*  or  of  immediate  extraction  of 
the  olfending  material,  the  eye  is  almost  always  lost  by 
the  subsequent  ju'oduction  of  a  suppurative  iridochoroiditis 
and  panophthalmitis;  and,  moreover,  the  condition  is  fre- 
quentl}^  the  cause  of  a  sympathetic  form  of  ophthalmia  in 
the  fellow-eye.  Five  well-known  cases  of  sympathetic  dis- 
ease studied  by  Coppez  were  all  duo  to  the  effects  of  the 
presence  of  foreign  bodies  in  the  ciliary  region. 

The  employment  of  antisepsis,  however,  has  dimin- 
ished considerably  the  frequency  of  these  formidable  com- 
plications, and  it  is  now  well  recognized  that  with  a  small, 
cleanly-incised  wound  of  the  ciliary  body  the  patient  has 
a  good  chance  of  escaping  the  various  forms  of  sympa- 
thetic lesion,  provided,  particularly,  if  he  be  in  good  health 
and  if  the  wonnd  has  remained  uninfected.  Even  when 
there  is  infection,  Abadie  and  other  surgeons^"  have  been 
able  to  combat  successfully  the  evil  results  i)y  such  rem- 
edies as  antiseptic  irrigations,  intraocular  and  subcon- 
junctival injections  of  corrosive  sublimate,  and  deep  ap- 
plications of  the  thermocauterv.     Oblemann's  statistics  of 

(61) 


02  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

566  cases  of  severe  wounds  of  the  eye^  in  100  of  which 
the  w^onnd  was  infected  or  was  complicated  by  the  pres- 
ence of  a  foreign  body,  and  in  which  there  were  but  2 
eases  of  sympathetic  disease,  distinctly  showed  that  very 
much  in  regard  to  prognosis  depends  upon  the  general 
condition  of  the  patient. 

Penetrating  wounds  of  the  selero-corneal  margin  are 
often  followed  by  the  condition  kno^^ll  as  "iridochorio- 
cyclitis."  This  may  be  acute  or  chronic  in  type.  As  a 
rule,  it  ends  in  atrophy  of  the  injured  eye  and  in  one 
of  the  plastic  forms  of  sympathetic  cyclitis  of  the  opposite 
eye,  these  results  often  appearing  after  months  of  severe 
suffering,  which  is  the  accompaniment  of  a  series  of 
inflammatory  attacks.  Suppurative  "iridochoriocyclitis" 
rarely  produces  sympathetic  ophthalmia. 

The  following  case  is  a  good  example  of  the  favorable 
termination  of  a  wound  of  this  latter  type: — 

Case  X  (personal  and  iinpublislied). — Penetrating  wound  of 
the  light  eye  involving  the  sclero-coineal  region  and  the  ciliary 
body.    Recovery. 

On  the  eighth  of  August,  189  -,  J.  L.,  a  30-year-old  man,  was 
struck  in  the  right  eye  by  a  piece  of  glass.  He  received  medical 
treatment  at  once. 

He  was  seen  by  the  author  eight  days  later.  At  that  time 
there  was  a  wound  of  tlie  cornea  which  was  two  centimeters  long, 
extending  obliquely  downward  and  inward  into  the  ciliary  region. 
The  tension  of  the  globe  was  somewhat  below  normal.  The  iris 
was  prolapsed,  and  the  pupil  was  reduced  to  a  minute  oval  slit 
which  was  displaced  toward  the  corneal  wound.  There  was  no 
marked  inflammatory  reaction,  and  the  patient  had  not  suffered 
any  acute  jjain.  The  eye  had  been  treated  by  leeching  and  the 
constant  application  of  compresses  which  had  been  soaked  in  a 
solution  of  boric  acid.  Tliis  treatment,  with  the  addition  of  irri- 
gations of  the  conjunctival  cul-de-fioc  with  corrosive-sublimate  solu- 
tions of  1  to  5000  strength  and  instillation  of  atropine  four  times 


Traumatic  Lesions  of  the  Eyeball.  33 

daily,  was  continued.  The  prolapsed  iris  was  not  excised.  The  left 
eye,  which  had  never  given  the  patient  any  trouble,  had  been 
phthisical  since  infancy. 

No  suppuration  occurred  and  the  iris-prolapse  gradually  dis- 
appeared, until  by  the  20th  of  November  of  the  same  year  the 
wound  had  healed  witliout  any  tendency  to  staphyloma.  The  iris 
was  adherent  to  tlie  cicatrix.  The  details  of  the  eyeground  could 
be  readily  seen  through  the  distorted  pupil.  Vision  corrected  with 
a  convex  spherical  lens  of  two  and  a  lialf  diopters'  strength  equaled 
five-sixths  of  normal. 

Wounds  of  the  posterior  segment  of  the  choroid  al- 
ways indicate  a  considerable  degree  of  traumatism;  and, 
as  has  been  stated  in  a  previous  chapter,  they  heal  rapidly 
when  they  are  aseptic  in  character  and  when  there  is  not 
any  marked  loss  of  the  vitreous  hunior.^' 

(a)  traumatic  hemorrhages  of  the  choroid. 

Hemorrhages  of  the  choroid  may  T)e  produced  by  any 
form  of  severe  blow  upon  the  eye,  the  temple,  tlie  fore- 
head, or  the  eyebrows  by  fists,  pieces  of  iron  or  wood,  etc., 
or  by  direct  penetrating  wounds.  They  are  most  fre- 
quently situated  in  the  anterior  part  of  the  membrane  in 
or  near  the  ora  serrata.  A  marked  predisposition  to  these 
types  of  extravasations  exists  in  patients  who  have  high 
degrees  of  myopia  or  who  are  suffering  from  heart  or  lung 
troubles,  arteriosclerosis,  uterine  affections,  anemia,  etc. 

These  facts  are  of  considerable  importance  to  the  ex- 
pert. Sometimes  the  extravasated  blood  infiltrates  through 
the  tissues  of  the  choroid  itself  (interstitial  hemorrhage), 
or  it  collects  in  the  suprachoroidal  spaces  between  the  cho- 
roid and  the  sclera.  Ordinarily  the  hemorrhages  are  not 
serious  and  do  not  disturb  vision  unless  they  are  very  ex- 
tensive or  are  situated  near  the  posterior  pole  of  the  eye  (a 
rare  condition).     The  interstitial  types  of  hemorrhage  are 


(J4  hijiirirs  hi  tlic  Eye  in   Ihtir  Medico-leytil  Aspcif. 

slowly  absorbed  and  often  leave  Ijeliind  tlieni  wliite  atro])liic 
areas  that  are  surrounded  with  pigment. 

Hemorrhagic  detachment  of  the  choroid,  Ijy  rupture 
of  an  important  ciliary  vessel,  usually  terminates  in 
phthisis  bulbi  from  a  gross  form  of  iridochoroiditis.  Pro- 
fuse extravasations  of  blood  may  also  lead  to  detachment 
of  the  retina,"'''  and  sometimes  to  its  rupture. 

According  to  de  Wecker,  Ijlood  may  find  its  way  into 
tbe  vitreous  hnnior  l)et\veen  the  fil)ers  of  the  optic  nerve, 
v.'ithout  rupturing  the  retimi.  Whatever  may  be  the  course 
of  the  extravasation,  the  ])rognosis  of  subretinal  hemor- 
rhages and  of  those  that  i)cnetrate  into  the  vitreous  cliam- 
ber  is  very  serious.  On  tlu'  contrary,  however,  if  the  pa- 
tient is  young  and  liealthy  and  if  the  extravasation  of 
l)lood  is  limited  in  amonnt  and  extent,  the  l)lood  may  be 
absorbed,  all  scotomata  disappear,  and  partial  vision  be 
restored. 

Case  XI  (personal  and  unpublished). — ^Multiple  traumatic 
lieniorrhages  into  the  choroid  and  the  vitreous  humor.     Recovery. 

On  the  eighth  day  of  March,  189  -,  A.  W..  a  28  year-old  black- 
smith, was  struck  on  the  left  eye  l)y  a  large  piece  of  iron.  Two 
hours  after  the  accident  the  lids  were  slightly  swollen.  There 
were  subconjunctival  eccliymoses  situated  to  the  outer  side  of 
the  cornea  and  the  pu])il  was  irregularly  dilated.  Vision  was 
markedly  decreased.  An  examination  witli  the  ophthalmoscope 
revealed  the  presence  of  a  series  of  minute  hemorrhages  that  were 
situated  in  the  anterior  part  of  the  choroid,  tliese  varying  in  size 
f)-oni  tliat  of  a  pinhead  to  tliat  of  a  ]iea.  Over  these  hemorrhages 
the  retinal  vessels  jaassed  intact.  Tiie  vitreous  humor  was  tilled 
with  numerous  floating  opacities. 

Three  leeches  were  applied  to  the  left  temple.  Compresses 
of  cold  solutions  of  boric  acid  were  placed  on  the  eyelids  and  atro- 
pine was  instilled  into  the  left  conjunctival  cul-de-sac  four  times 
a  day.     One  week  later  the  cold  compresses  were  discontinued. 

In  two  months'-  time  the  absorption  of  the  hemorrhages  was 


Traumatic  Lesions  of  the  Eyeball.  55 

complete  and  with  a  convex  spherical  lens  of  one  and  a  quarter 
diopters'  strengtli  visual  acuity  was  increased  to  five-sixths  of 
normal.    There  were  defects  in  the  corresponding  visual  field. 

In  other  cases  sight  may  be  immediately  and  perma- 
nently abolished,  the  eye  becoming  disorganized  by  a  de- 
tachment of  the  vitreous  hnmor  and  retina  from  profuse 
hemorrhaged^ 

The  detached  and  lacerated  retina  may  become  in- 
flamed, followed  later  by  a  cicatricial  contraction  of  the 
retinal  tissues,  wbich  will  seriously  compromise  vision.  It 
is  consequently  imperative  to  observe  such  cases  for  pro- 
longed periods  of  time  before  an  opinion  as  to  prognosis 
can  be  given . 


o* 


(b)  ruptures  of  the  choroid. 

As  the  result  of  a  contusion  or  a  direct  compression 
of  the  eyeball  or  as  the  consequence  of  a  shock  that  has 
been  imparted  to  the  orbital  or  the  periorbital  bones  by  a 
blunt  body,  the  choroid,  together  with  the  external  layers  of 
tlie  retina,  may  become  ruptured  and  torn  in  one  or  more 
places,  the  otlier  ocular  coats  remaining  uninjured  (so- 
caUed  isolated  ruptures  of  the-  choroid*''^).  In  the  great  ma- 
jority of  such  cases,  this  solution  of  continuity  of  the  cho- 
roidal tissues,  which  is  usually  single,  is  situated  between 
the  optic  disk  and  the  macula  lutea.  On  account,  in  part, 
of  the  marked  extensibility  of  the  choroidal  membrane  in 
the  equatorial  portion  of  the  eyeball,  the  break  is  rarely 
seen  in  this  position.  At  times  it  has  been  found  in  the 
anterior  portion  of  the  membrane  near  the  ora  serrata  and 
the  ciliary  region.  Cases  of  double,  triple,  and  even  quad- 
ruple rupture  have  been  seen  and  reported  by  Teillais,  Fage, 
and  others. 


66  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

When  the  blood  that  is  extravasated  into  the  anterior 
chamber  or  that  is  infiltrated  into  the  vitreous  humor  does 
not  prevent  an  ophthalmoscoiDic  examination  of  the  eye- 
ground  the  cleanly-cut  rupture  may  be  plainly  seen  at  the 
time  of  its  production.  Later  a  cicatrix  in  the  region  of  the 
macula  lutea  will  be  found  exhibiting  its  characteristic 
form  of  a  pearly-white,  curved  streak  that  is  bounded  by  a 
pigmented  border  and  which  is  surrounded  by  an  irregular 
pigment-area.  In  front  of  this  the  vessels  of  the  retina, 
unless  they  have  been  divided  at  the  time  of  the  accident, 
will  be  found  to  pass  intact. 

The  prognosis  of  choroidal  ruptures  depends  upon 
the  intensity  of  the  wounding  force,  upon  the  character 
and  the  degree  of  the  lesions  that  have  been  produced  in 
other  parts  of  the  eye  (hemorrhages  into  the  vitreous 
humor,  detachments  of  the  retina,  etc.),  and  upon  subse- 
quent complications,  such  as  iritis,  retinitis,  etc.®^ 

Multiple  ruptures,  which  are  the  result  of  violent  con- 
tusions, are  generally  accompanied  by  rupture  of  the  sclera. 
These  usually  terminate  in  the  loss  of  the  eye. 

When  the  rupture  is  simple,  it  ordinarily  merely  gives 
rise  to  disturbances  during  attempts  that  are  made  for 
direct  vision,  and  tends  to  produce  scotomata  that  vary  con- 
siderably in  direct  accordance  with  the  seat  and  the  extent 
of  the  rupture  itself. 

At  first  vision  is  so  profoundly  altered  that  the  pa- 
tient in  many  instances  is  not  able  to  see  to  count  fingers 
even  at  a  short  distance  in  front  of  the  eye.  This  is  par- 
ticularly so  if  there  has  been  an  intraocular  hemorrhage. 
Sight,  however,  often  becomes  rapidly  better  at  the  end 
of  several  weeks'  time.  At  times  there  is  a  return  to 
almost  normal  visual  acuity,  but  such  cases  are  rare;  so 
that  too  much  caution  cannot  be  exercised  in  any  medico- 


Truumatic  Lesions  of  the  Eyeball.  67 

legal  report  as  to  the  certainty  of  restitution  of  vision  or 
even  its  preservation  after  such  a  form  of  injury. 

Sometimes  any  central  or  peripheral  form  of  scoto- 
mata  that  may  have  been  due  to  a  compression  of  the  ret- 
inal elements  by  bloody  effusion  may  become  manifest  to 
its  maximum  extent  and  density  immediately  after  the 
accident;  but  with  the  return  of  direct  visual  acuity  such 
breaks  and  gaps  in  the  field  of  vision  may  gradually  dis- 
appear as  the  sanguineous  effusion  is  absorbed. 

The  persistence  of  amblyopia  and  of  scotomata  indi- 
cates in  many  such  cases  that  the  retina  has  been  involved 
at  the  same  time  as  the  choroid.  The  ophthalmoscope  will, 
moreover,  reveal  the  alterations  that  have  been  undergone 
by  the  retina, — this  complication  only  too  often  terminat- 
ing in  a  monocular  form  of  blindness  which  ordinarily  fol- 
lows atrophy  of  the  optic  nerve  and  retina. 


CHAPTEE  Y. 


Eetina. 


On  accoimt  of  its  situation,  tlie  retina  is  seldom,  if 
ever,  injured  alone.  In  the  study  which  has  been  made 
of  penetrating  wounds  of  the  eyeball  it  has  been  shown 
that  slight  solutions  of  continuity  of  the  choroid  and  the 
retina,  which  are  produced  by  aseptic  pointed  and  cutting 
instruments,  heal  promptly  and  produce  functional  dis- 
turbances of  merely  relative  importance.  In  such  cases, 
particularly  after  a  wound  of  the  retina,  there  remains  but 
a  pigmented  cicatrix,  which  adheres  to  the  choroid. 

As  a  rule,  traumatic  lesions  of  the  retina  are  dnc  to 
contusion  of  the  eyeball,  which  is  either  direct  or  is  pro- 
duced by  contrecovp,  or  are  dependent  upon  penetration  of 
a  foreign  body.  The  list  of  the  most  common  types  of 
injuries  comprise  shock,  hemorrhage,  rupture,  detachment, 
and  the  presence  of  foreign  bodies. 

(a)    shock,   EUPTURE,   HEMOREHAGE,    and   TRAtTMATIC 

DETACHMENT. 

Berlin,^^  who  has  studied  shock  of  the  retina,  both 
clinically  and  experimentally,  has  noted  the  occurrence  of 
the  following  symptoms  at  the  time  of  the  accident:  Local- 
ized pericorneal  injection,  pain  in  the  ciliary  region, 
marked  photophobia,  great  resistance  of  the  iris  to  the 
action  of  atropine,  and  decrease  of  central  vision  without 
any  appreciable  contraction  of  the  visual  field. "•'^  With 
the  ophthalmoscope  he  sometimes  found,  particularly  in 
the  vicinity  of  the  macula  lutea  and  the  optic  disk,  and 

(G8) 


Traumatic  Lesions  of  the  Eyeball.  59 

at  times  in  other  places,  according  to  tiie  location  of  the 
traumatism,  edematous  and  grayish  nebulous  foci  in  front 
of  which  the  retinal  vessels  passed  intact.  The  optic  disk 
itself  was  generally  hyperemic.  He  noticed  that  these 
cloudy  disturbances  gradually  decreased,  disappearing  about 
the  third  day. 

Berlin  also  demonstrated  that  experimental  contusions 
jjroduced  similar  lesions,  and  determined  the  presence  of 
bloody  effusions  that  were  situated  between  the  ciliary 
muscle  and  the  sclera,  the  sclera  and  the  choroid,  and  the 
choroid  and  the  retina. 

The  visual  disturbances  which  this  author  has  de- 
scribed as  being  due  to  irregular  astigmatism  following 
deformity  of  the  crystalline  lens  from  compression  by 
hemorrhagic  foci  in  the  ciliary  region,  and  which  other 
authors  ascribe  to  disturbance  of  accommodation  are,  how- 
ever, just  as  transient  as  the  retinal  halo  itself.  Neverthe- 
less, as  de  Wecker  has  shown,  atrophy  of  the  retina  and  of 
the  optic  nerve  (probably  from  injury  to  tlie  retrobulbar 
portion  of  the  optic  nerve)  has  been  seen  to  develop  after 
a  contusion  of  the  eyeball  in  which  no  appreciable  lesion 
of  the  fundus  of  the  eye  could  be  detected. 

Temporary  subnormal  color-perception  and  amblyopia 
without  lesion  discoverable  with  the  ophthalmoscope  have 
likewise  followed  injuries  to  the  head,  and  have  been  recog- 
nized after  so-called  simple  shock  to  the  eyeball  (Wilson 
and  Tyndall,  Favre).  Before  attributing  either  of  these 
conditions  to  any  definite  variety  of  traumatic  anesthesia 
which  is  supposed  to  have  been  caused  by  "molecular  shock 
of  the  retina,"  the  medical  expert  must  determine  that  he 
is  not  dealing  with  a  case  of  toxic  or  hystero-traumatic 
amblyopia  or  with  disturbances  due  to  paralysis  or  spasm 
of  the  ciliary  muscle,  etc. 


70  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

The  functional  or  subjective  symptoms  that  traumatic 
hemorrhages  of  the  retina  produce  are  dependent  mainly 
upon  the  position  and  the  amount  of  the  sanguineous  ex- 
travasation. The  slightest  hlood-area  or  even  the  finest 
punctate  hemorrhage  in  the  immediate  vicinity  of  the 
macula  lutea  may  cover  extraneous  objects  with  red-  or 
even  green-  colored  clouds.  In  some  cases  there  may  be 
such  conditions  as  metamorphopsia  or  momentary  losses  of 
central  vision.  Peripheral  hemorrhages  give  rise  to  ex- 
centrically-placed  scotomata.  Blood-extravasations  in  the 
neighborhood  of  the  ora  serrata  do  not  produce  any 
troublesome  visual  disturbances,  and,  as  a  rule,  are  only 
recognized  subjectively  with  the  ophthalmoscope. 

Most  of  the  traumatic  forms  of  retinal  hemorrhages 
recover  without  any  appreciable  alteration  in  visual  acuity. 
An  exception  should  be  noted  in  cases  of  hemorrhages  in 
the  macular  region  and  in  those  in  which,  on  account  of 
their  size  and  extent,  absorption  is  so  slow  as  to  allow  either 
fatty  degeneration  of  the  retinal  tissue  or  the  formation  of 
localized  pigment-spots  to  take  place  (Hersing,  Delacroix/* 
Berlin/^  and  Poncet*'^).  More  recently  de  Lapersonne  and 
Yassaux®^  have  described  a  pigmentary  form  of  infiltration 
of  the  retina  following  certain  types  of  traumatism  of  the 
eye  which  is  similar  to  that  seen  in  pigmentary  retinitis, 
especially  in  cases  of  injuries  to  the  optic  nerve  and  to  the 
neighboring  vessels. 

Large  effusions  sometimes  detach  the  retina  or  else 
tear  it  and  thus  invade  the  vitreous  chamber,  giving  rise 
at  times  to  a  pigmented  form  of  connective-tissue  material 
which  becomes  fibrous,  producing — upon  contracting — 
complete  atrophy  of  the  retina. 

In  consequence  of  direct  contusion  of  the  eyeball 
(usually  the  result  of  the  impact  of  a  blunt  body  of  small 


Traumatic  Lesions  of  the  Eyeball.  71 

size)  the  retina  may  present  a  series  of  isolated  ruptures 
situated  toward  the  posterior  pole  of  the  eye,  and  which 
the  ophthalmoscope  makes  evident  under  the  form  of 
chalk-white  cicatrices  bordered  with  pigment.  If  the 
tears  have  been  complete,  the  retinal  vessels  disappear  at 
the  position  of  the  cicatrices;  if  the  solutions  of  continuity 
have  involved  only  the  external  layers  of  the  retina,  they 
pass  over  the  tear  intact. 

Immediately  following  such  an  accident  the  patient 
usually  complains  of  a  considerable  degree  of  diminution  of 
visual  acuity,  and  is  apt  to  note  the  presence  of  varying 
types  of  scotomata.  These  functional  forms  of  visual  dis- 
turbance may  become  better  for  a  time  as  the  extravasation 
is  absorbed;  but  later  cicatricial  contraction  produces 
destruction  of  the  perceptive  elements  of  the  retina,  giving 
rise  to  almost  complete  abolition  of  sight.  Prognosis, 
therefore,  in  most  cases  is  very  unfavorable. 

Traumatic  detachment  of  the  retina — that  is,  separa- 
tion of  the  retina  from  the  choroid — is  produced  in  dif- 
ferent ways.  It  has  been  seen,  in  connection  with  the 
subject  of  injuries  of  the  sclera,  that  penetrating  wounds 
of  the  eyeball  and  foreign  bodies  in  the  eye  may  produce 
bloody  effusions  between  the  two  internal  envelopes  of  the 
eye.  The  lesion  may  also  be  the  immediate  consequence 
of  extensive  loss  of  vitreous  humor,  or  later  of  cicatricial 
contraction  existing  between  the  vitreous  body  and  the 
wound  itself.  At  times  the  retinal  detachment  is  hemor- 
rhagic in  nature,  the  result  of  a  contusion  of  the  globe  by 
a  blow  from  a  fist,  a  fragment  of  wood,  a  stone,  etc. 

The  functional  symptoms  seen  in  these  cases  vary, 
being  in  direct  relation  with  the  seat  and  the  extent  of 
the  detachment,  as  well  as  being  dependent  upon  the  pres- 
ence of  lesions  of  the  choroid  and  other  parts  of  the  eye. 


72  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

In  most  cases  the  patient  complains  of  an  immediate  dis- 
turbance of  vision.  He  wall  assert  that  he  is  barely  able 
to  distinguish  gross  objects^  such  as  the  upheld  fingers,  and 
only  at  a  short  distance  in  front  of  the  eye.  If  the  macular 
region  be  invaded,  central  vision  is  ofttimes  practically 
abolished;  whereas,  on  the  other  hand,  sight  will  only  be 
decreased  in  proportionate  degree  if  the  detachment  is 
peripheral.  The  visual  field  will  present  contractions  and 
blind  areas  corresponding  precisely  with  the  portions  of 
the  retina  that  are  detached.  In  most  cases  objects  will 
appear  more  or  less  distorted  (metamorphopsia). 

Traumatic  detachment  of  the  retina  is  not  so  serious 
as  are  the  other  varieties  of  retinal  detachment.  Indeed, 
there  are  instances  of  complete  recovery  in  cases  of  this 
type  of  disorders.    (Yon  Graefe,  Galezowski,  Armaignac. '"''*) 

Prognosis  is  in  direct  relation  with  the  position  and 
the  extent  of  the  lesion,  though  ordinarily  the  traumatic 
form  of  the  affection  has  a  tendency  to  improve  by  absorp- 
tion of  the  effusion. 

(b)  foreign  bodies  in  the  eetina  and 
IN  the  choroid."" 

When  propelled  hj  a  sufficient  force,  grains  of  lead, 
sharp  metallic  particles,  pieces  of  percussion-caps,  frag- 
ments of  stone,  etc.,  pass,  as  a  rule,  through  the  corneal 
membrane,  the  iris,  and  the  crystalline  lens.  If  they  enter 
the  eyeball  through  the  sclera,  they  may  lodge  either  in 
the  crystalline  lens  or  pass  directly  into  the  vitreous  humor; 
or  thev  mav  become  fixed  in  the  choroid,  the  retina,  or  the 
optic  nerve-head.  On  account  of  the  comparative  thinness 
of  the  two  intimately-associated  membranes  (the  retina  and 
the  choroid)  foreign  bodies  are  usually  imbedded  in  them 
at  the  same  time,  sometimes  penetrating  into  the  scleral 


Traumativ  Lesions  of  the  Eyehall.  73 

covering.  In  consequence,  it  is  best  to  consider  the  aifec- 
tions  of  the  two  coats  at  the  same  time. 

Out  of  seventy  cases  of  foreign  bodies  sitnated  in  the 
posterior  hemisphere  of  the  eyeball,  Coppez  {loco  citato) 
fonnd  bnt  two  in  which  the  choroid  and  the  retina  were 
involved.  They  are,  therefore,  in  accordance  with  his  ex- 
perience, relatively  rare. 

If  the  foreign  body  is  small  in  size,  and  if  it  is  smooth, 
aseptic,  and  but  slightly  or  not  at  all  oxidizable,  it  may 
become  encysted  and  remain  harmless  in  the  two  mem- 
branes after  having  produced  a  slight  inflammatory  reac- 
tion. Careful  perimetric  examination  in  such  cases  often 
reveals  the  presence  of  interruptions  in  the  visual  field 
corresponding  with  those  that  are  seen  in  cases  of  the  cir- 
cumscribed foci  of  retino-choroidal  inflammation,  or  de- 
tachment. Central  vision  in  many  such  cases  may  remain 
intact.  Hirschberg,  Mengin,  Landesberg,  Knapp,  Hosch, 
de  Gonzenbach,  Eoy,  and  others  have  published  cases  of 
this  kind."''  Some  years  ago  the  author  had  under  his  care 
a  patient — a  weigher  at  a  mint — whose  left  eye  had  been 
injured  by  a  chip  of  steel,  the  offending  particle  being 
lodged  in  the  retina.  Eecovery  with  normal  visual  acuity 
took  place  and  has  remained  to  this  day. 

Case  XII  (personal  and  unpublished). — Foreign  body  in  the 
retina.     Encystment.     Recovery  witli  normal  vision. 

On  the  thirteenth  of  December,  188-,  B.  T.,  a  32-year-old 
weigher,  was  struck  in  the  left  eye  by  a  piece  of  steel.  There  was 
no  apparent  reaction,  except  a  small  subconjunctival  ecchymosis 
which  was  situated  near  the  inner  canthus.  The  patient  com- 
plained of  a  sensation  of  slight  heaviness  in  tlie  eyeball,  but  the 
globe  was  not  painful  on  pressure.  Visual  acuity  equaled  four- 
fifths  of  normal. 

The  piece  of  steel  had  struck  the  eye  at  the  inner  corneal 
limbus,  producing  a  wound  barely  half  a  millimeter  long.     Near 


74  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

the  periphery  of  the  iris,  directly  opposite  the  corneal  wound,  there 
was  a  minute  oval  opening.  The  pupil  was  the  same  size  as  its 
fellow,  and  there  Mas  not  any  hemorrhage  into  the  anterior 
chamber. 

Ophthalmosco])ic  examination  showed  that  the  crystalline 
lens  and  the  vitreous  humor  were  transparent.  A  fragment  of 
metal  could  be  plainly  seen  in  the  forward  part  of  the  retina  to  the 
inner  side.  Surrounding  the  foreign  body  was  a  narrow  zone  of 
edema. 

The  patient  was  inged  to  consent  to  extraction  of  the  foreign 
mass  as  a  means  to  protect  his  eye  from  immediate  or  subsequent 
danger.     He  refused  to  permit  any  operative  intervention. 

The  eye  was  treated  by  the  employment  of  constant  applica- 
tions of  boric-acid  compresses  and  the  use  of  instillations  of  atro- 
pine four  times  daily. 

During  the  next  few  days  the  eye  became  slightly  injected, 
the  pupil  slowly  dilated,  and  the  retinal  edema  increased.  The 
vitreous  humor  and  the  crystalline  lens,  however,  remained  trans- 
parent. Central  vision  continued  normal;  but  the  visual  field  was 
contracted  on  the  outer  side. 

In  nearly  four  weeks'  time  the  foreign  body  was  hidden  by  a 
grayish-white  exudate  tliat  was  the  size  of  the  head  of  a  large  pin. 

Three  weeks  later  the  patient  resumed  his  work.  At  this  time 
his  visual  acuity  had  become  normal,  though  the  outer  part  of  the 
visual  field  still  remained  contracted.  Seven  years  after  the  acci- 
dent the  patient  consulted  the  author  for  the  treatment  of  a  super- 
ficial burn  of  the  cornea,  at  which  time  it  was  found  that  excellent 
visual  acuity  with  the  eye  still  remained. 

In  the  majority  of  cases  the  prognosis  is  not  favorable, 
encystment  with  preservation  of  good  visual  acuity  being 
a  rare  exception. 

The  seriousness  of  prognosis  in  such  cases,  however, 
depends  largely  upon  the  situation  of  the  wound  and  upon 
the  character  of  the  tissues  that  have  been  injured.  For 
example,  the  results  of  the  passage  of  a  foreign  body 
through  the  sclera  in  the  equatorial  region  of  the  eyeball 
gives  rise  to  much  less  serious  consequences  than  if  the 


Traumatic  Lesions  of  the  Eyeball.  75 

mass  had  passed  through  the  iris,  the  crystalline  lens,  the 
vitreous  humor,  or  the  ciliary  body. 

Moreover,  encystment  of  the  mass  itself  tends  to  pro- 
tect the  eye  from  all  subsequent  danger.  The  inflamma- 
tory exudate  enveloping  the  foreign  body  in  the  choroidal 
membrane  may,  however,  frequently  become  infiltrated 
with  lime-salts,  and  thus  prove  a  source  of  irritation;  or, 
as  the  result  of  a  subsequent  traumatism,  the  mass  may 
rupture  and  the  foreign  body  be  set  free,  thus  giving  rise 
to  more  or  less  serious  complications. 

The  contraction  of  the  connective  tissue  surrounding 
the  foreign  material  may  lead  to  secondary  detachment  of 
the  retina. 

Usually,  penetrating  substances  arc  infected  and  pro- 
duce violent  inflammation,  which  rapidly  destroys  the  eye. 
In  other  cases  inflammatory  reaction,  though  less  intense 
and  more  limited,  may  lead  to  atrophy  of  the  organ. 

Kostenitsch's  examinations  of  twenty  human  eyeballs 
that  had  been  enucleated  on  account  of  penetrating  wounds 
caused  by  pieces  of  percussion-caps  have  confirmed  the  re- 
sults of  the  experiments  that  have  been  made  by  Leber  on 
the  effects  of  the  influence  of  metallic  foreign  bodies  upon 
the  eyes  of  rabbits.  Copper,  by  its  chemical  action,  pro- 
duces suppuration  without  the  intervention  of  micro-or- 
ganisms. This  is  more  marked  when  the  metal  comes  into 
contact  with  the  muscular  parts  of  the  eye,  while  inflam- 
matory reaction  reaches  its  height  when  the  metallic  chip 
becomes  fixed  in  the  retina  in  the  vicinity  of  the  optic  disk 
or  in  the  ciliary  body.'^^  In  a  discussion  on  Leber's  com- 
munication upon  "Injuries  of  the  Eye  Caused  by  Pieces 
of  Copper," '-  Kipp  and  Meyer  reported  cases  of  preservation 
of  the  eye  with  good  visual  acuity  after  the  penetration  of 
fragments  of  gun-caps  into  the  retinal  tissues. 


76  Injuries  to  the  Eye  in  their  Medico-legal  Asi)ect. 

In  cases  in  which  the  injured  eye  preserves  a  certain 
degree  of  vision  the  visual  fiekl  presents  scotomata  that 
correspond  either  with  localized  retinal  detachments  from 
chorio-retinal  hemorrhages  or  from  areas  of  circumscrihed 
chorioretinitis.  It  must  not  be  forgotten  that  detachment 
of  the  retina  is  not  always  an  immediate  result,  it  appear- 
ing gradually  in  some  cases  and  reaching  such  a  degree,  at 
times,  as  to  produce  blindness. 

To  summarize:  the  presence  of  foreign  bodies  in  the 
choroid  and  the  retina  presents  a  most  imfavorable  prog- 
nosis from  the  stand-point  of  the  conservation  of  the  visual 
function  of  the  injured  eye.  Moreover,  the  foreign  mate- 
rials frequently  serve  as  the  starting-points  for  the  condi- 
tion known  as  sympathetic  ophthalmia. 


CHAPTER  VI. 

Crystalline  Lens." 

The  manifestations  of  tranmatism  of  the  crystalline 
lens  are  classified  under  three  heads:  (A)  traumatic  luxa- 
tions [and  subluxations];  (B)  traumatic  cataract;  (C)  for- 
eign bodies  in  the  crystalline  lens. 

(a)  traumatic  luxations  and  subluxations,'^* 

The  crystalline  lens  is  displaced  generally  as  the  re- 
sult of  concussion  from  a  violent  shock  sustained  by  the 
skull  or  the  body,  or  by  the  stroke  of  a  whip,  or  as  the 
result  of  a  wound  which  involves  the  zonule  of  Zinn.  The 
position  assumed  by  the  crystalline  lens  differs  in  accord- 
ance with  the  direction  that  has  been  taken  by  the  offending 
object.  The  degree  of  violence  of  the  traumatism  to  which 
the  structures  of  the  organ  has  been  subjected  and  the 
j)revious  presence  of  pathological  conditions  such  as  are 
found  in  high  myopia,  anterior  staphylomata,  etc.,  also 
become  important  factors  in  the  question.  Congenital 
ectopia  and  a  fluid  condition  of  the  vitreous  body  are 
additional  predisposing  causes. 

The  crystalline  lens  may  be  tilted  and  undergo  verti- 
cal or  a  lateral  displacement,  remaining,  in  part,  lodged 
in  the  hyaloid  fossa  (subluxations'^^),  luxated  either  into 
the  anterior  chamber  or  into  the  vitreous  humor,  or,  as  has 
been  seen  while  studying  traumatic  lesions  of  the  sclera, 
it  may  be  forced  into  the  subconjunctival  cellular  tissue'^'' 
and  even  expelled  from  the  eye. 

(77) 


78  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

Inclination  and  lateral  displacement  of  the  crystalline 
lens  give  rise  to  characteristic  objective  symptoms,  namely: 
inequality  of  the  depth  of  the  anterior  chamber  and  tremor 
of  the  iris,  with  certain  ophthalmoscopic  signs.  Not  less 
distinct  are  the  visual  disturbances.  Subluxations,  accord- 
ing to  their  variety  and  their  degree  of  displacement,  are 
followed  by  a  loss  of  the  power  of  accommodation,  by  a 
certain  degree  of  irregular  myopic  astigmatism,  and,  in  the 
cases  of  marked  deviation,  by  the  phenomena  of  monocular 
diplopia  and  polyopia.  Finally,  luxations  may  become 
complete  and  the  crystalline  lens  assume  a  cataractous  con- 
dition. 

A  subluxation  may,  moreover,  be  the  starting-point 
for  the  condition  known  as  chronic  glaucoma,  with  or 
without  obliteration  of  the  angle  of  filtration:  a  lesion  of 
which,  to-day,  there  is  a  tendency  to  consider,  by  some, 
not  as  primary,  but  as  secondary  to  the  glaucomatic^^ 
process. 

In  a  general  way,  except  in  cases  in  which  traumatism 
restores  vision  by  displacing  a  crystalline  lens  that  is  cat- 
aractous, even  partial  luxations  of  the  lens  always  disturb 
vision,  especially  for  near-work.  After  complete  rupture 
of  its  suspensory  apparatus  the  lens  either  passes  forward 
into  the  anterior  chamber,  between  the  iris  and  the  cornea, 
or  is  forced  backward  into  the  vitreous  body.  In  some 
cases  it  remains  engaged  in  the  pupillary  orifice  and  may 
give  rise  to  glaucomatous  symptoms. 

If  the  capsule  of  the  crystalline  lens  is  ruptured,  the 
lens  itself  may  become  rapidly  opaque  and  the  symptoms 
of  glaucoma  appear  at  once.  If  the  capsule  is  uninjured, 
it  may  temporarily  remain  relatively  harmless  and  trans- 
parent in  the  aqueous  humor.  In  the  course  of  time,  how- 
ever, it,  as  a  rule,  becomes  adherent  to  either  the  iris  or  the 


Traumatic  Lesions  of  the  Eyeball.  79 

cornea,  and,  as  one  of  the  results,  produces  an  ulcerative 
form  of  keratitis  or  a  chronic  glaucomatous  iridocyclitis; 
so  that,  in  the  great  majority  of  such  cases,  operation  be- 
comes necessary.  As  a  rule,  extraction  of  the  cataractous 
lens  is  not  particularly  easy.  The  procedure  necessitates 
the  employment  of  chloroform  or  ether  narcosis  and  favor- 
able results  cannot  always  be  secured  on  account  of  the 
presence  of  other  lesions  of  the  eye  and  of  the  loss  of 
vitreous  humor  at  the  time  of  the  operation. 

Dislocation  of  the  crystalline  lens  into  the  vitreous 
humor  is  more  frequent  and  is  less  serious.  As  in  the  pre- 
ceding types,  if  the  capsule  is  intact  it  may  not  cause 
any  reaction  for  years;  the  unused  eye  acts  just  as  in  the 
case  of  aphakia.  At  other  times,  on  account  of  its  great 
mobility,  the  diseased  lens  may  become  the  primary  cause 
of  chronic  iridocyclitis,  of  glaucoma,  or  of  sympathetic 
complications. 

(b)  traumatic  oataract.'^^ 

According  to  some  statistics,  traumatic  cataract  is 
found  from  three  to  five  times  in  one  thousand  cases  of 
diseases  of  the  eye.  Experiments  by  Berlin,  Schirmer, 
Stein,  and  others,  as  well  as  clinical  observations,  show 
that  so-called  simple  shock  of  the  crystalline  lens  may 
produce  an  opacity  which  is  either  partial  or  complete, 
and  that  such  an  opacity  may  be  transient  or  permanent. '^^ 
Typical  traumatic  cataract  usually  results  from  the  direct 
action  of  pointed,  cutting,  or  blunt  instruments,  or  by  the 
presence  of  a  foreign  body,  which,  after  penetrating  the 
coverings  of  the  eye,  injures  the  lenticular  capsule  and  the 
lens-fibres  themselves.  Sometimes  the  crystalline  lens  is 
displaced  by  rupture  of  the  zonule  of  Zinn. 


so  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

Most  prominent  in  the  list  of  wounding  agents  stand 
metallic  chips,  lead  shot,  points  of  scissors,  needles,  knives, 
and  pens.  This  is  followed  hy  contusions  of  the  eyeball, 
caused  hy  blows  from  fists,  rnl)ber  balls,  and  corks.  Se- 
vere shocks  to  the  sknll  or  to  the  skeleton  may  indirectly 
produce  lacerations  of  the  anterior  or  the  posterior  lentic- 
ular capsule,  with  frequent  rupture  of  the  suspensory  liga- 
ment of  the  lens. 

From  a  medico-legal  stand-point  it  is  important  to  re- 
member that  l)y  some  it  is  stated  that  an  opacity  of  the 
crystalline  lens  may  not  appear  until  a  long  period  of  time 
after  an  accident-";  so  that  unilateral  cataracts  which  are 
apparently  idiopathic  in  type  may,  in  reality,  often  be  due 
to  the  penetration  of  some  foreign  body,  or  may  be  sec- 
ondary to  deeper  forms  of  lesion  of  the  eyeball,  such  as 
choroidal  rupture  and  detachment  of  the  retina.  Becker 
and  others  have  for  a  long  time  drawn  attention  to  this 
point. 

.  In  all  cases  the  iris  should  be  examined  carefully  in 
order  to  determine  whether  there  is  any  minute  break  in 
its  tissue  or  any  loss  of  substance,  as  these  conditions  fre- 
quently indicate  the  direction  of  the  track  of  a  wounding 
agent.  "Beware  of  traumatic  cataracts,"  said  Trelat;  ''they 
accompany  traumatisms  in  all  of  their  varieties,  and  are  fre- 
quently associated  with  all  their  consequences."  "It  is  the 
half-successes  and  the  failures,"  he  asserts,  "which  make  up 
the  balance-sheets  of  the  operative  treatment  of  traumatic 
cataract."^^  He  believes  that  "as  a  general  statement,  every 
injury  to  the  crystalline  lens  should  be  considered  as  a  seri- 
ous menace  for  the  existence  of  an  eye."^^ 

Traumatic  cataracts  are  often  complicated;  but  the 
complications  seen  in  such  cases  vary  with  each  particular 
instance.     In  fact,  no  affection  demands  of  the  surgeon 


Traumatic  Lesions  of  the  Eyeball.  gl 

more  caution  in  prognosis  nor  more  competency  and  pa- 
tience in  treatment.  They  may  be  divided  into  partial  or 
total,  and  can  be  sululivided  into  simple  and  complicated. 

Cataracts  caused  by  shock  or  contusion,  without  per- 
foration of  the  moinbranes  of  the  eye  and  without  con- 
comitant lesions  of  tlic  (U^eiior  parts  of  the  organ,  often 
recover  without  any  complication  and  with  satisfactory 
visual  acuity.  Such  cases  are  rarely  infected.  A  small  for- 
eign body  or  a  sharp-pointed  aseptic  instrument  will  make 
a  minute  opening  in  the  lenticular  capsule,  and  may  pro- 
duce an  opacity  of  the  lens,  the  absorption  of  which  will 
be  the  more  rapid  and  the  more  complete,  the  younger  the 
patient.  If  the  capsular  wound  is  quite  narrow,  however, 
and  especially  if  it  is  in  contact  with  the  iris,  the  return 
of  the  transparency  of  the  lens  will  be  often  prevented  by 
a  too  early  cicatrization,  so  that  as  a  result  a  partial  capsulo- 
lenticular  opacity  which  will  diminish  direct  vision,  unless 
the  injury  is  in  the  equatorial  region,  may  be  formed. 

Haltenhoff,"-'*  in  his  report  upon  the  "Treatment  of 
Traumatic  Cataract,""  cites  the  case  of  a  mechanic  whose 
crystalline  lens  became  cataractous  in  consequence  of  the 
penetration  of  a  chip  of  metal,  the  patient  returning  to  his 
work  with  a  normal  visual  acuity  at  the  end  of  a  month's 
time. 

On  account  of  the  retraction  and  a  curving  of  the 
edges  of  the  capsular  wound  an  extensive  laceration  of  the 
capsule  of  the  crystalline  lens  may  produce,  as  a  rule,  a 
complete  lenticular  opacity.  This  is  generally  followed  by 
an  absorption  of  the  cataract.  The  process,  which  is  rapid 
and  nearly  always  complete  in  childhood  and  in  youth,  is 
usually  slow  and  incomplete  in  the  adult  and  in  the  aged 
subject.  Absorption  may  begin  many  months  after  an 
accident,  and  thus  cause  a  disappearance  of  the  opacities 


83  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

that  have  been  stationary  nntil  that  period  of  time.  Eare 
cases  have  been  reported  in  which  such  cataracts  have  been 
absorbed  at  an  advanced  age.  One  case  in  a  patient  fifty- 
eight  years  old  was  seen  by  Haltenhoff  and  another  by 
Steffan  in  a  sixty-nine-year-old  subject.  De  Wecker  con- 
siders infection  a  most  important  factor  in  the  develop- 
ment of  such  types  of  cataract. 

Moreover,  an  eye  which  has  recovered  a  fair  degree 
of  visual  acuity  after  the  removal  of  such  a  cataract  can 
generally  be  employed  only  to  increase  the  extent  of  the 
visual  field.  It  cannot  be  used  for  near-work,  unless  the 
fellow-eye  has  a  lower  grade  of  vision. 

Infection  is  to  be  feared  the  most  when  the  ocular 
tissues  have  been  contused  or  extensively  lacerated,  and 
thus  becomes  a  serious  complication  of  the  traumatic  form 
of  cataract.  A  simple  prick  of  an  infectious  character,  for 
example,  may  be  followed  by  a  keratitis  and  an  iritis  with 
hypopyon. 

Iritis  is  a  most  common  condition.  According  to 
Pruet  (loco  citato),  it  is  found  in  GG  per  cent,  of  all  cases. 
It  frequently  develops  into  a  chronic  form  of  iridocyclitis. 
Chemosis,  palpebral  edema,  and  purulent  infiltration  of  the 
cornea  indicate  a  deeper  type  of  inflammation  and  bespeak 
the  beginning  of  a  panophthalmitis.  If  such  a  condition 
occurs  an  early  enucleation  or  evisceration,  when  possible, 
should  be  performed  in  order  to  protect  the  fellow-eye  from 
sympathetic  disease  and  to  allow  the  patient  to  return 
earlier  to  his  work.  If  the  surgeon  has  been  sufficiently 
fortunate  to  check  suppuration,  a  long  period  of  time 
should  be  allowed  to  elapse  before  any  attempt  toward 
operative  measures  for  the  improvement  of  vision  is  made. 
In  addition  there  must  be  a  certainty  that  the  inflammatory 
processes  have  subsided.    Intraocular  tension  must  be  nor- 


Traumatic  Lesions  of  the  Eyeball.  g3 

mal  (de  Lapersonne®^),  and  perception  of  light  throughout 
the  ordinary  visual  field  area  must  he  good. 

Too  often,  indeed,  a  too-early  operative  intervention 
provokes  an  insidious  typo  of  iridocyclitis,  which  will  oh- 
struct  the  pupil,  and  even  permanently  aholish  the  function 
of  vision. 

Traumatic  cataract  may  be  also  complicated  hy  many 
non-infectious  conditions,  among  which  are  glaucoma,  luxa- 
tion of  the  lens,  the  presence  of  foreign  bodies,  and  injuries 
to  other  parts  of  the  eye, — -the  consequences  of  which  in 
themselves  are  most  variable.  When,  for  example,  a  large 
opening  of  the  lenticular  capsule  of  an  adult  patient  gives 
easy  access  to  the  aqueous  humor,  the  crystalline  lens  often 
swells  considerably  during  the  first  few  days  and  gives  rise 
to  symptoms  of  secondary  glaucoma.  Such  glaucomatous 
signs  are  favored  by  the  non-elasticity  of  the  ocular  mem- 
branes in  patients  of  advanced  age,  by  the  improper  use 
of  atropine,  and  by  displacement  of  the  crystalline  lens, 
particularly  in  cases  in  which  the  lenticular  equator  irri- 
tates the  ciliary  region. 

Later  the  adhesion  of  the  capsule  of  the  lens  to  the 
cicatrix  of  the  corneal  wound  is  an  additional  cause  of 
increased  tension.  The  discussion  which  took  place  at  the 
1894  Congress  of  the  French  Ophthalmological  Society  has 
shown,  however,  that  this  type  of  glaucoma  need  not  be 
particularly  feared,  and  that,  if  infection  or  deep  anatom- 
ical disorders  do  not  produce  too  great  disturbance,  sub- 
sequent operative  procedure  adapted  to  each  individual 
case  may  give  rise  to  relatively  useful  results. 

The  final  effects  of  such  operations,  however,  are  fjn- 
from  always  being  as  encouraging  as  the  statistics  of 
Coppez,-^  for  example,  would  lead  one  to  hope,  in  which, 
out  of  45  cases  treated  by  aspiration,  there  were  42  sue- 


84  Injuries  tu  the  Eye  in  their  Medico-legal  Aspect. 

cesses,  with  visual  acuities  varying  from  one-fourtli  to  one- 
third  of  normal,  (rayet,  on  the  contrary,  out  of  12  opera- 
tions for  simple  traumatic  cataract  obtained  the  following 
results:  In  1  case  vision  equaled  one-half;  in  2  instances 
it  was  one-fifth;  in  4  cases  it  was  one-tenth;  in  2  it  was 
less  than  one-tenth;   and  in  3  it  was  merely  (quantitative.'"' 

Conclusions:  The  course  and  the  prognosis  of  a  trau- 
matic cataract  differ  markedly  in  accordance  with  the  sep- 
tic or  the  aseptic  condition  of  the  wounding  agent,  the 
amount  of  injury  that  has  been  done  to  the  crystalline 
lens,  to  the  age  of  the  patient,  and  to  the  condition  of  the 
other  parts  of  the  eye. 

The  most  serious  cases  are  those  which  result  from 
contused  wounds  of  the  anterior  segment  of  the  eyeball, 
the  cataract  in  such  instances  frequently  constituting  only 
an  accessory  and  a  secondary  form  of  lesion. 

In  very  young  subjects  spontaneous  and  complete  ab- 
sorption of  a  simple  traumatic  cataract  is  not  uncommon; 
and,  if  the  pupillary  area  has  been  freed  by  a  retraction  of 
the  capsule,  the  patient  is,  from  the  stand-point  of  vision, 
in  a  similar  condition  to  one  who  has  been  operated  upon 
for  simple  senile  cataract.  Likewise,  a  partial  opacity  of 
the  crystalline  lens  has  an  opportunity  of  disappearing; 
and,  if  the  opacity  is  located  peripherally,  it  offers,  as  a 
rule,  but  a  slight  hinderance  to  the  visual  function. 

If  the  patient  has  passed  the  age  of  adolescence,  ab- 
sorption will  be  less  complete  and  not  so  rapid,  and  if, 
as  is  so  frequent,  the  injury  to  the  lens  is  complicated  by 
an  inflammation  of  the  iris,  posterior  synechia — with  more 
or  less  extensive  and  dense  capsular  deposits — may  be  pro- 
duced, the  consequences  of  these  conditions  being  most  un- 
favorable for  the  re-establishment  of  useful  vision. 


Traumatic  Lesions  of  ihc  Eyehall.  85 

(O)    FOKEIGN    BODIES    IN    THE    CRYSTALLINE   LENS." 

Since  the  etiology  of  foreign  bodies  in  the  crystalline 
lens  is  about  the  same  as  that  of  foreign  bodies  in  the  iris, 
it  seems  unnecessary  to  repeat  in  extemo  what  has  been  said 
before  on  the  subject. 

The  facts  furnished  by  the  patient  will  ofttimes  help 
to  make  a  diagnosis  that  is  sufhciently  accurate  to  deter- 
mine, in  measure,  the  consequences  of  such  lesions  and  to 
permit  the  institution  of  the  most  appropriate  and  effective 
forms  of  treatment.  In  general,  however,  too  great  impor- 
tance must  not  be  attributed  to  the  statements  of  patients, 
because  they  are  frequently  unintentionally  erroneous  in 
character.  It  is  better  to  depend  upon  a  direct  and  a 
careful  examination.  Differential  diagnosis  is  far  from 
always  easy.  The  presence  of  a  foreign  body  in  the  crystal- 
line lens  can  often  be  determined  l)y  means  of  oblique 
illumination.  If  the  foreign  material  is  small  and  if  it  be 
superficially  located,  it  will  usually  remain  visible  as  long 
as  the  lens-tissue  itself  preserves  a  definite  degree  of  trans- 
parency. Such  was  the  case  in  one  of  the  author's  patients, 
in  whose  riglit  lens  a  particle  of  steel  was  fixed,  the  chip 
of  metal  being  quite  easily  seen  for  six  weeks'  time  after 
the  date  of  traumatism. 

The  presence  of  a  small  wound  of  the  cornea  and  iris 
witli  an  o])acity  of  the  crystalline  lens,  following  an  acci- 
dent to  the  eye,  is  presumptive  evidence.  The  discovery  of 
a  foreign  body,  however,  is  sometimes  rendered  quite  dif- 
ficult by  its  peripheral  situation  and  by  the  existence  of 
posterior  synechia  which  })revent  the  dilatation  of  the 
pupil,  thus  not  allowing  a  thorough  examination  of  the 
lens  itself  possible.  In  addition,  a  previous  or  an  advanced 
opacity  in  the  lens  may  conceal  the  foreign  substance. 


g(5  Tvjurics  to  the  Eye  in,  their  Medico-lrtinl  Axprct. 

At  times,  a  yellowish-oclire-like  tint,  with  a  point  of 
maximum  intensity  in  some  portion  of  a  traumatic  cataract 
corresponding  with  a  cicatrix  in  the  cornea,  is  a  sign  of  the 
probahle  presence  of  an  oxidizable  metallic  chip  (0.  Becker, 
Samelsohn,  Ansin).  Quite  frequently  the  foreign  body 
does  not  become  apparent  until  after  an  absorption  of  a 
part  of  the  cataract.  It  may  also  happen  that  the  foreign 
material  has  passed  through  the  crystalline  lens  and  has 
become  lodged  in  the  \dtreous  humor.  In  some  cases  the 
maintenance  of  a  full  field  of  good  perception  of  light  in- 
dicates that  the  foreign  body  is  probably  neither  in  the 
vitreous  humor  nor  in  the  retina  and  posterior  portion  of 
the  choroid. 

Finally,  it  is  not  uncommon  for  a  small  foreign  body 
to  glance  from  the  anterior  surface  of  the  crystalline  lens, 
after  having  injured  it,  and  to  fall  into  the  anterior  cham- 
ber, from  which  posit«ion  the  surgeon  should  extract  it  as 
quickly  as  possible.     (Stellwag  von  Carion.) 

The  ordinary  result  of  the  penetration  of  a  foreign 
body  into  the  crystalline  lens  is  the  formation  of  a  partial 
or  a  total  cataract.  This  opacification,  as  a  rule,  will  be 
the  more  rapid  aud  the  more  extensive  the  greater  is  the 
laceration  of  the  lens-capsule  and  the  deeper  is  the  pene- 
tration of  the  foreign  body  into  the  lenticular  substance. 

A  small,  pointed,  and  aseptic  foreign  body  introduced 
into  the  superficial  and  the  peripheral  layers  of  the  crystal- 
line lens  may  remain  harmless  for  years,  having  produced 
but  a  limited  area  of  opacity,  with  a  slight  diminution  in 
visual  acuity.  To  the  cases  of  Desmarres,  Galezowski, 
Snell,  de  Wecker,  and  others,  the  author  takes  the  oppor- 
tunity to  add  the  following: — 

Case  XIIT  (personal  and  unpublished). — Foreign  body  (steel 
chip)   in  the  riwlit  r-rystalline  lens.     Recovery  a\  itii   noininl  vision. 


Trannifitic  Lcsjonfi  of  ihe  Eyehdll.  87 

J.  G.,  18  years  old,  an  apprenticed  mechanic,  believed  that 
he  had  gotten  a  piece  of  steel  into  his  right  eye  while  he  was  en- 
graving. As  he  had  no  acute  pain,  and  as  his  eye  was  not  inflamed, 
he  continued  his  work  for  fifteen  days,  until  May  28,  1886.  At 
that  time  he  consulted  the  author  on  account  of  a  blurring  of 
vision  in  the  right  eye  that  had  annoyed  him  for  a  period  of 
several  days. 

Examination  of  the  right  eye  showed,  with  oblique  illumina- 
tion, a  corneal  cicatrix  which  was  barely  one  millimeter  in  length. 
The  scar  was  situated  in  the  inferior  nasal  portion  of  the  membrane. 
Directly  back  of  this  the  pupillary  edge  of  the  iris  presented  a 
minute  nick  in  its  tissue,  at  which  point  there  was  an  adhesion  to 
tlie  anterior  capsule  of  the  crystalline  lens.  The  lens  itself  ap- 
peared somewhat  clouded.  At  this  visit  the  patient  was  able  to 
see  to  count  fingers  at  one  meter's  distance. 

After  the  instillation  of  several  drops  of  a  solution  of  atro- 
pine a  black  body,  about  the  size  of  a  pin's  head,  could  be  seen 
located  on  the  anterior  surface  of  the  upper  third  of  the  crystal- 
line lens.     From  this  point  opaque  strias  radiated  in  all  directions. 

The  opacification  extended  slowly  in  the  cortical  layers  of 
the  lens  for  about  a  month's  period  of  time,  while  vision  became 
increasingly  disturbed.  The  eyeball  itself  did  not  present  any 
signs  of  gross  inflammatory  reaction. 

On  the  seventh  of  July  the  patient  was  again  seen.  It  was 
then  found  that  only  a  slight  and  superficial  opacity  could  be 
determined  near  the  chipping  of  steel.  With  a  convex  spherical 
lens  of  1  ^/i  diopters'  strength  visual  acuity  with  the  affected  eye 
equaled  five-sixths  of  normal. 

Four  years  later  the  patient  returned  for  the  treatment  of  a 
burn  of  the  left  upper  eyelid.  At  this  visit  it  was  determined  that 
the  vision  of  the  affected  organ  was  fully  preserved. 

It  must  be  remembered  that  the  composition  of  the 
foreign  body  is  of  the  greatest  importance.  Splinters  of 
glass  are  well  tolerated,  while  chips  of  copper  and  bits  of 
percussion-caps,  for  example,  produce  marked  inflamma- 
tory symptoms.  This  innocnousness  of  some  forms  of  for- 
eign bodies,  however,  may  be  bnt  temporary,  and  the  ma- 
terials may  give  rise,  after  varying  lapses  of  time,  to  in- 


88  ])ijii)i>s  fit  the  Kyc  hi  thrir  Medicn-h'ijnl  Af^prct. 

flammatory  reaction.  To  the  dangers  already  mentioned 
as  the  resnlt  of  this  condition  must  be  added  those  which 
come  from  the  formation  of  areas  of  degeneration  in  the 
crystalline  lens  and  from  the  immediate  or  subsequent 
escape  of  a  foreign  body  into  the  anterior  or  posterior 
chamber.  Should  the  latter  occur,  repeated  attacks  of 
iritis  and  iridochoriocyclitis  may  be  produced,  which  will 
be  frequently  followed  by  loss  of  tlie  eye  and  at  times  lead 
to  sympathetic  disease. 

Prognosis  in  such  cases,  therefore,  is  unfavorable,  the 
conditions  frequently,  if  incapsulation  does  not  take  place, 
remaining  threatening  until  the  cataractous  lens  and  the 
foreign  bodies  have  been  extracted.  This  operation,  how- 
ever, which  is  quite  a  delicate  one,  is  not  free  from  danger, 
the  results,  moreover,  not  always  being  satisfactory;  hence 
the  medical  expert  should  not  formulate  a  definite  opinion 
upon  the  final  outcome  of  such  an  accident  until  after  an 
adequate  and  extended  observation  of  the  patient  has  been 
made. 

Direct  extraction  of  fragments  of  steel  and  of  iron 
that  have  become  fixed  in  the  cortical  layers  of  the  crystal- 
line lens  is  greatly  facilitated  by  the  use  of  magnetic  in- 
struments, or  of  the  electro-magnet,  such  as  those  of  Hirsch- 
berg,  McHardy,  and  Haab.  As  soon  as  possible  after  the 
accident,  an  ordinary  electro-magnet  or  a  magnetic  lance 
(Hirschberg)  should  be  introduced  into  the  lens  either 
through  the  wound  of  entrance  of  the  foreign  body  or 
through  an  incision  especially  made  for  the  purpose.  Some 
operators  prefer  to  extract  small,  superficially  located  par- 
ticles by  means  of  a  pair  of  curetting  forceps. 


CHx^PTEE  VII. 

Vitreous  Humok.*^ 

The  lesions  here  comprise:  (.4.)  wounds;  (B)  foreign 
bodies  in  tlie  vitreons  humor. 

(a)  wounds  of  the  vitreous  humor. 

Injuries  to  the  vitreous  liunior  have  abeady  been  in- 
cidentally discussed  in  connection  with  penetrating  wounds 
of  the  sclera.  It  has  been  there  seen  that  the  results  of 
this  variety  of  traumatism  have  their  maximum  importance 
when  there  is  an  associated  lesion  of  the  ciliary  body,  con- 
siderable loss  of  the  vitreous  humor,  abundant  intraocular 
hemorrhage,  and  deep  penetration  of  a  septic  foreign  body 
In  the  last  condition  there  is  generally  a  rapid  develo*pment 
(if  a  suppurative  form  of  hyalitis,  while  the  contents  of  the 
vitreous  chamber  are  converted  into  an  abscess-mass. 

Although  it  is  not  immediately  serious,  traumatic  in- 
flammation of  the  vitreous  humor  of  plastic  type  (plastic 
liyalitis)  following  penetrating  wounds  caused  by  pointed 
and  cutting  instruments,  whether  complicated  or  not,  pro- 
duces, as  a  rule,  irremediabb>  distnrbances  of  the  visual 
fimctions.  Indeed,  it  is  well  known  that  the  form  of  local- 
ized chronic  hyalitis  which  is  caused  by  small  pointed  in- 
struments (needles,  bodkins,  etc.)  generally  terminates  in 
tlic  formation  of  connective-tissne  bands  which  slowly  in- 
vade the  entire  vitreous  chaniljer.  Gradual  contraction  of 
this  newly-formed  tissue  ensues,  while  the  retina,  the  vit- 
reous humor,  and  the  choroid  become  detached  and  the 
evebaH   ntropbies  without  the  apjiearance  of  anv  marked 

■  (89) 


90  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

reaction.  Frequently  blindness  becomes  absolute  and  per- 
manent. 

The  gravity  of  lesions  of  the  ciliary  body  and  the  re- 
sults of  loss  of  the  vitreous  humor  have  been  sufficiently 
dwelt  upon  in  the  preceding  chapters  of  this  work. 

Generally  blood  is  extravasated  into  the  vitreous  humor 
as  the  result  of  blows  given  to  the  eyeball  in  cases  of  rupt- 
ure of  the  choroid,  and  penetrating  wounds  of  either  the 
posterior  ocular  hemisphere  or  the  ciliary  region  of  the 
globe.  Organic  and  functional  disorders  necessarily  vary 
with  the  situation  and  the  amount  of  the  effusion,  and  are 
always  in  direct  relation  with  the  previous  condition  of  the 
injured  organ. 

The  prognosis  of  jjrofuse  hemorrhages  is  most  unfavor- 
able, for  the  eye  is  nearly  always  disorganized  by  contrac- 
tion of  the  vitreous  humor  and  detachment  of  the  retina. 
At  times  vision  remains,  but  it  is  ordinarily  complicated 
with  the*  presence  of  blind  areas  (scotomata).  In  a  young 
patient  and  in  a  sound  eye  such  a  hemorrhage,  if  of  mod- 
erate intensity,  has  every  chance  of  becoming  absorbed,  but 
recovery  often  takes  months  for  accomplishment,  and  as 
one  of  the  permanent  results  one  or  more  movable  scoto- 
mata often  remain.  Necessarily,  the  defects  in  the  visual 
field  will  be  permanent  when  the  choroid  and  the  retina 
have  been  injured.  In  mild  cases  the  opacities  in  the  vit- 
reous humor  may  disappear  in  several  weeks'  time,  the  pa- 
tient ceasing  to  complain  of  the  cloudiness  of  vision  or  of 
the  muscse  which  had  formerly  obscured  his  view,  while 
visual  acuity  again  becomes  normal. 

In  every  case  the  physician  who  is  called  upon  as  an 
expert  witness  should  reserve  his  prognosis  until  he  can 
examine  fully  the  condition  of  the  eye,  particularly  the 
state  of  the  interior  of  the  oru'nu. 


Traiininfio  Lesions  of  the  Eyehall.  91 


(b)  fokeign  bodies  in  the  vitreous  humor. 


89 


More  than  oiie-lialf  of  the  foreign  bodies  which  pene- 
trate into  the  interior  of  the  eye  throngh  wounds  in  the 
cornea  or  the  anterior  portion  of  the  sclera  pass  througli 
the  iris-tissue,  the  ciliary  body,  and  the  crystalline  lens.*"' 
Frequently  the  choroid  and  the  retina  are  injured,  and  the 
foreign  mass  either  falls  to  the  most  dependent  part  of  the 
organ,  or,  according  to  its  weight,  its  form,  the  force  of  its 
propulsion,  and  the  consistency  of  the  vitreous  humor,  re- 
mains in  that  portion  of  the  eye.  Such  foreign  objects 
usually  consist  of  minute  pieces  of  iron  or  of  steel,  grains 
of  lead,  chips  of  percussion-caps,  stone,  etc.  More  rarely, 
pieces  of  wood  and  eyelashes  are  carried  into  the  vitreous 
chaml^er  by  metallic  particles.  Although  the  size  of  such 
foreign  bodies  is  generally  small,  yet  quite  large  masses  of 
foreign  material  have  been  ol)served  (Hirschberg,  et  al.). 

The  ophthalmoscope  not  infrequently,  particularly  if 
the  fundus  of  the  eye  can  be  seen,  enables  the  course  which 
foreign  bodies  have  taken,  as  well  as  the  position  of  their 
final  location,  to  be  recognized.  Usually,  however,  there  is 
an  effusion  of  Mood,  an  injury  to  the  crystalline  lens,  or  a 
detachment  of  the  retina. 

As  a  rule,  the  patient  complains  immediately  after  the 
accident  of  varying  types  of  visual  disturbance,  such  as 
scotomata  and  peripheral  contractions  of  the  visual  field. 
At  times,  central  vision  is  markedly  diminished  or  it  may 
be  almost  entirely  abolished,  as  in  the  types  of  complete 
traumatic  cataract  or  in  extensive  hemorrhages  into  the 
vitreous  humor. 

When  a  direct  examination  cannot  be  made,  the  diffi- 
culties of  diagnosis  become  ver}^  great.  Under  such  cir- 
cnm-^tauecs.  the  patient  and  his  friends  mnst  be  carefully 


92  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

questioned  as  to  the  circumstances  under  which  the  acci- 
dent occurred  and  should  be  asked  to  describe  the  form,  the 
nature,  and  the  probable  course  of  the  projectile.  The  situ- 
ation, the  character,  and  the  direction  of  the  corneal  or 
the  scleral  wound,  the  nature  of  the  injury  to  the  crystal- 
line lens  itself,  the  rapidity  of  the  loss  of  sight,  and  the 
occurrence  of  bubbles  of  air  in  the  vitreous  chamber 
(Hirschberg  and  Hildebrand)  are  all  ini})ortant  conditions 
which  make  a  diagnosis  probable,  but  not  certain.  In  some 
cases  a  foreign  body  may  pass  through  the  eyeball  and 
escape  either  into  the  orbital  cavity  or  go  still  farther  back. 

In  cases  in  which  the  presence  of  metallic  particles  of 
iron  or  of  steel  are  suspected  the  diagnosis  can  be  made 
much  more  certain  by  the  employment  of  a  so-called  mag- 
netic needle.  Various  forms  of  rotating  apparatus  which 
will  permit  the  locality  of  an  iron  or  steel  fragment  l)y 
angular  deviation  of  a  needle  or  some  other  form  of  indi- 
cation to  be  determined  have  been  devised  for  this  pur- 
pose (Pooley,  Pagenstecher,  Asmus,  etc.^^).  Coppez  and 
Gallemaerts  have  shown  that  the  magnetometer  of  Gerard 
can  be  usefully  employed  for  this  purpose,  they  having 
found  that  it  indicates  the  presence  in  the  eye  of  a  mag- 
netic form  of  foreign  body  of  even  one-half  a  milligramme 
weight,  and  that  it  serves  to  give  useful  information  as  to 
the  position  of  the  mass."" 

In  a  general  way,  the  jjrognosis  in  such  cases  is  quite 
serious,  this  being  true  in  spite  of  the  recent  improvements 
in  operative  interference  and  technique  (Hirschberg,  May- 
weg,  Hildebrand,''^  and  Haab).  Such  cases  are  particularly 
desperate  when  a  foreign  body  is  contaminated,  it  being 
very  apt  to  rapidly  produce  a  general  suppuration  of  the 
eyeball.  This  is  particularly  true  when  there  is  pro- 
nounced intraocular  hemorrhage.  M^hen  the  escape  of  vit- 


Traumatic  Lesions  of  the  Eyeball.  93 

reous  humor  lias  been  ahimdant^  and  when  the  iris,  and, 
especially,  the  crystalline  lens  have  been  injured.  The 
lens-tissue  itself  is  a  particularly  favorable  soil  for  the  cult- 
ure of  infectious  germs.  In  this  connection  de  Wecker  has 
pertinently  remarked  that  the  surgical  dressings  in  such 
cases  are  often  much  nu)re  dangerous  than  the  presence  of 
aseptic  foreign  bodies  themselves. 

Very  rarely  a  smooth,  aseptic,  and  non-oxidizablc  body 
may  be  definitely  tolerated.  Generally,  however,  after  a 
more  or  less  prolonged  period  of  quietness,  its  presence,  or, 
more  frequently,  its  displacement,  becomes  the  starting- 
point  for  an  attack  of  iritis  or  a  chronic  plastic  form  of 
hyalitis,  which  is  followed  by  a  detachment  of  the  retina 
and  by  a  shrinkage  of  the  vitreous  humor.  These  types  of 
lesions  ordinarily  terminate  in  the  destruction  of  the  organ 
or  may  produce  sympathetic  disease  and  even  disturbances 
in  the  general  health.  It  is  true,  nevertheless,  that  a  cer- 
tain number  of  cases  of  encystment  of  foreign  bodies  with 
preservation  of  good  vision  have  been  published  (von 
Jaeger,  von  Graefe,  Pfliiger,''*  and  Hirschberg);  but,  as 
Yvert  has  most  properly  observed,  there  has  been,  as  a 
ru.le,  too  much  haste  in  drawing  favorable  conclusions  from 
such  observations. 

The  experiments  of  Leber  show  very  well  that  the 
reaction  of  an  eye  wounded  in  this  manner  depends  in 
measure  upon  the  size  and  upon  the  chemical  nature  of 
the  foreign  substance,  upon  its  septic  or  aseptic  state, 
and  upon  its  situation.  ISTon-oxidizable  metallic  particles, 
free  from  infectious  germs,  do  not,  as  a  rule,  produce  any 
appreciable  inflammation;  while  almost  all  authorities  have 
recognized  the  relative  benignity  of  wounds  of  the  vitreous 
body  and  of  the  deep  membranes  of  the  eye  by  lead  shot 
of  small  calibre, — which  are  sterilized  in  some  way,  par- 


9-1.  Injuries  to  the  Eye  in  their  Medieo-leyul  Aspect. 

ticularly  by  the  explosion  of  the  powder  (Eolland,  Forna- 
tola"^).  Oxidizable  aseptic  metals,  with  the  exception  of 
copper'"^  and  metallic  mercury,  although  producing  sup- 
puration, serve,  nevertheless,  as  agents  for  the  starting- 
points  of  more  or  less  serious  lesions  in  accordance  with 
their  positions  and  their  relative  size. 

As  in  the  great  majority  of  cases  the  foreign  bodies 
in  the  vitreous  humor  are  composed  of  iron  or  steel,  mag- 
netic instruments  or  electro-magnets"'  are  among  the  use- 
ful agents  for  their  removal.  In  such  cases  the  small,  mag- 
netic probe  of  Collin  is  of  use,  as  in  the  following  instance: 

Case  XIV  (personal). — Metallic  fragments  in  the  vitreous 
humor  of  the  right  eye.  Extraction  with  the  magnet  of  Collin. 
Suture   of  the   conjunctival   membrane.     Eecovery. 

F.  D.,  a  locksmith,  47  years  of  age,  consulted  the  author  on 
the  eleventh  of  July,  1884,  one-half  liour  after  an  injury  to  his 
right  eye  by  a  piece  of  hot  iron.  The  metallic  body  had  struck  tlic 
eyeball  four  millimeters  behind  the  sclero-corneal  border,  and  had 
produced  a  wound  of  the  sclerotic  of  about  five  millimeters  in 
length,  just  above  the  insertion  of  the  internal  rectus  muscle. 
There  was  a  slight  prolapse  of  the  vitreous  humor.  The  pupil  was 
dilat<>d.  Ophthalmoscopic  examination  showed  an  elevation  of 
tlie  retina  situated  in  the.  region  corresponding  with  the  woimd. 
This  swelling  was  apparently  caused  by  an  effusion  and  extended 
into  the  vicinity  of  the  optic  disk.  Beneath  this  area  a  blackish 
foreign  body  could  be  plainly  seen.  Vision  was  reduced  to  one- 
thirtieth  of  normal.  The  patient  complained  only  of  a  feeling  of 
weight  in  the  eye. 

Under  chloroform  narcosis,  the  author  carefully  probed  the 
M'ound  and  discovered  a  piece  of  metal  at  its  lower  angle  near  an 
opening  of  the  sclera.  A  Collin  magnet  was  introduced  into  the 
eyeball  through  the  woimd,  and,  at  the  first  trial,  a  flat,  triangular 
chip  of  iron  was  extracted,  this  being  obtained  with  but  a  slight 
loss  of  vitreous  humor.  After  thorough  irrigation  of  the  wound 
with  a  solution  of  boric  acid,  the  conjunctival  break  was  sutured 
and  cold  dressings  were  applied. 

On  the  third  day  the  suture  was  removed.     Compression  was 


Traumatic  Lesions  of  the  Eyeball.  95 

continued  until  tlie  twenty-fifth  day,  by  wliich  time  the  scleral 
wound  had  healed.  At  that  time  visual  acuity  had  risen  to  two- 
thirds  of  normal. 

Tlie  chances  of  success  in  such  cases  are  good  when 
tlie  foreign  body  is  small,  when  it  is  so  situated  that  it  can 
1)6  easily  reached  without  producing  too  much  damage  to 
the  ocular  structures,  and  when  attempts  to  extract  the 
mass  are  made  immediately  after  the  accident.  Eemoval 
by  means  of  strong  electro-magnets  which  work  at  a  dis- 
tance is  preferable  in  many  eases  to  procedures  that  neces- 
sitate the  introduction  of  instruments  into  the  vitreous 
humor, — as  the  presence  of  such  contrivances  themselves 
in  the  ocular  tissues  exposes  the  organ,  not  only  to  in- 
fection, but  to  inflammatory  reaction  and  degenerative 
changes.  Haab  has  been  successful,  by  means  of  a  powerful 
form  of  instrumentation,  in  ejecting  through  the  wound 
of  entrance  chips  of  iron  and  steel  that  have  been  located 
in  the  vitreous  chamber  and  in  the  retinal  membrane.'*® 

This  propitiousness  of  result  is  not  the  case  if  the 
nature  or  the  position  of  the  foreign  body  cannot  be  diag- 
nosticated sufficiently  early  after  the  date  of  traumatism. 
Under  such  circumstances  it  is  preferable  in  some  cases 
not  to  make  any  operative  interference  unless  the  actual 
existence  of  the  eve  is  threatened;  in  others  the  trial  mav 
be  worth  attempting. 

Efforts  at  extraction  have  undoubtedly  at  times  been 
followed  by  complete  sticcess;  nevertheless  some  of  the 
so-termed  recoveries  cannot  be  considered  as  permanent, 
for  the  loss  of  vitreous  humor  which  generally  accom- 
panies such  an  operation  with  subsequent  cicatricial  con- 
traction of  the  wound  may  ultimately  give  rise  to  the 
loss  of  an  eye  that  had  been  considered  as  saved.  As  far 
as  the  preservation  of  vision  is  concerned,  the  results  that 


9G  Injuries  to  the  Ei/c  in  Ihcir  Medico-lrgal  Aspect. 

are  permanently  obtained  are  far  less  brilliant  than  those 
which  have  been  gotten  immediately  after  the  operation. 
According  to  the  statistics  of  Snelb'"'  Horner,'' °"  Schiess- 
Gemnseus/'^^  Hirschberg  {loco  cifalo),  and  others,  resultant 
vision  in  such  cases  has  remained  satisfactory  in  about  10 
to  15  times  out  of  100.  Hildcbrand's  figures  are  somewhat 
more  satisfactory,  showing  a  jiroportion  of  31  recoveries  out 
of  100  cases, — the  shape  of  the  eye  being  preserved  in  one- 
half  of  the  number  of  cases. 


CHAPTER  VIII. 

Traumatic  Lesions  of  the  Eye  as  a  Whole. 

In  order  to  comj^lete  the  study  which  has  been  made 
of  injuries  of  the  various  parts  of  the  visual  organ,  a  few 
words  upon  those  cases  in  which  the  traumatism  involves 
almost  the  entire  eyeball  may  be  advantageously  added. 
Those  forms  of  multiple  and  complex  lesions,  of  which 
connected  and  logical  descriptions  could  not  be  well  given 
in  the  preceding  chapters,  comprise  ordinarily:  (A)  con- 
tusions, luxation,  and  avulsion  of  the  eyeball;  (B)  wounds 
and  burns  of  the  eyeball. 

(a)  contusion,  luxation,  and  avulsion  of 
the  eyeball. 

It  has  been  known  since  the  discovery  of  the  ophthal- 
moscope that  various  functional  disorders  which  w'ere 
formerly  attributed  to  "commotion"  of  the  globe,  sine 
materia,  are  in  reality  the  results  of  contusion,  and  are 
associated  with  definite  aaatomical  changes,  the  gravity  of 
these  lesions,  in  a  general  way,  being  proportional  to  the 
violence  and  the  character  of  the  traumatism.  In  deter- 
mining the  extent  of  the  damage  that  has  been  produced 
by  a  traumatism  and  what  proportion  of  a  lesion  is  due  to 
the  condition  of  the  patient,  the  medical  expert  must  take 
into  consideration  the  previous  condition  of  the  organ, 
its  degree  of  prominence,  the  state  of  its  refraction,  and 
the  age  of  the  patient.  Thns,  in  the  following  case  the 
author's  conclusions  would  have  been  at  variance,  if  a 
myopia  of  very  high  degree  had  not  existed. 

^  (97) 


98  Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

Case  XV  (personal  and  unpublished) . — Contusion  of  a  my- 
opic eye.  Traumatic  detachment  of  the  retina.  ]\Iedico-legal 
report. 

The  author  was  appointed  a  medical  expert  by  the  first 
Chamber  of  the  Civil  Court  of  the  City  of  Lille,  with  instructions 
to  determine  "the  present  condition  of  V.'s  right  eye;  to  decide  if 
this  condition  is  the  result  alone  of  the  blow  inflicted  upon  it  by 
D.,  or,  if  it  should  be  ascribed  partly  to  the  blow  and  partly  to 
individual  condition,  what  might  be  the  results  of  such  conditions, 
and  what  consequences  might  arise  in  the  future." 

According  to  the  official  documents  and  to  information 
elicited  from  both  sides  of  the  case,  V.,  during  a  dispute  on  the 
morning  of  the  thirtieth  of  September,  189-,  had  been  struck 
violently  upon  the  right  eye  by  D.  Several  hours  after  the  acci- 
dent the  patient  was  seen  by  a  physician,  who  found  that  "the 
right  eye  was  blood-shot  and  the  conjunctiva  was  injected."  As 
the  physician  did  not  detect  any  serious  lesions,  and  did  not  make 
an  examination  of  the  fundus  of  the  eye,  he  decided  that  the 
patient  would  be  able  to  return  to  work  in  a  few  days'  time. 

Dujardin,  who  was  consulted  some  days  later,  recognized  and 
certified  to  the  existence  of  a  "detachment  of  the  lower  portion  of 
the  retina,  with  ])robable  rupture  of  the  clioroid."  Subsequent 
certificates  from  Dujardin  established  the  fact  that,  in  spite  of  the 
medical  treatment,  the  retinal  detachment  had  increased,  and  the 
acuity  of  vision  had  progressively  decreased. 

V.  was  certain  that  before  the  date  of  the  blow  the  vision 
of  his  right  eye  was  excellent,  and  that  it  had  enabled  him  to  per- 
form his  work  satisfactorily.  He  had  worn  a  concave  spherical 
lens  of  five  diopters'  strength  for  a  long  time.  Several  hours  after 
the  accident  he  was  able  with,  however,  the  greatest  difficulty,  to 
write  a  letter,  which  was  dictated  to  him  in  the  office  of  his  lawyer. 
Since  then  his  sight  has  gradually  diminished,  and  at  the  time 
of  examination  he  asserted  that  he  could  not  walk  alone  with  any 
degree  of  surety  or  security,  a  grayish-white  cloud  constantly  float- 
ing before  his  eyes. 

On  examination  a  few  "blackish"  spots,  though  quite  fre- 
quently of  a  "violet"  tint,  with  balls  of  fire,  abruptly  i-an  across 
his  fields  of  vision. 

The  left  eye  had  been  rendered  useless  by  a  total  staphyloma, 
and  had  been  enucleated  about  six  years  previously  on  -account  of 


Traumatic  Lesions  of  the  EyeMll.  99 

severe  pain.  Since  that  time,  until  the  thirtietli  day  of  December, 
he  had  not  consulted  an  ophthalmologist. 

W^ien  V.  came  to  tlie  author's  office  he  was  led  by  the  hand, 
and  seemed  incapable  of  finding  his  way  alone  in  a  place  that  was 
not  familiar  to  him.  Careful  examination,  after  correction  of  his 
refractive  error,  showed  that  central  visiuil  acuity  was  reduced  to 
about  one-thirtieth  of  normal. 

There  was  a  marked  defect  in  the  upper  half  of  the  visual 
field  for  both  colors  and  form — in  which  position  he  was  unable  to 
see  to  distinguish  fingers  that  were  moved  close  in  front  of  his  eye. 
The  cause  of  this  marked  decrease  in  the  visual  function  was 
sought  for  by  a  careful  examination  of  the  ocular  symptoms,  both 
externally  and  internally,  and  the  following  conditions  were  dis- 
covered: The  superior  orbital  arch  projected  sufficiently,  and  the 
eyeball  was  not  unduly  prominent.  The  lids,  the  eyebrows,  the 
conjunctiva,  and  the  cornea  did  not  present  a  trace  of  recent  or  of 
old  traumatism.  The  free  edge  of  the  eyelids  was  the  seat  of  a 
minor  degree  of  inflammation.  The  cornea  was  transparent  and  the 
iris  appeared  normal.  The  pupil  was  circular  and  was  moderately 
dilated.  The  iris  reacted  normally  under  the  influence  of  the  usual 
stimuli.  Careful  examination  of  the  iris  revealed  tlie  presence  of 
a  slight  tremor  at  its  periphery,  as  if  the  crystalline  lens  under 
the  influence  of  some  traumatism  had  undergone  a  partial  displace- 
ment. The  tension  of  the  eyeball  was  rather  less  than  normal. 
The  right  eye  deviated  slightly  outward,  this  strabismus  apparently 
being  due  to  a  minor  degree  of  insufficiency  of  the  internal  rectus 
muscles. 

Examination  of  the  media  by  the  aid  of  focal  illumination  and 
the  ophthalmoscope  revealed  the  presence  of  several  faint  stria  in 
the  crystalline  lens,  as  well  as  a  slight  cloudiness  in  the  vitreous 
humor.  The  most  important  lesion  was  found  located  in  the 
retina.  This  membrane  exhibited  an  extensive  detachment  in  its 
inferior  half,  the  detached  portion  assuming  the  form  of  an  un- 
dulating surface  with  a  bluish-gray  reflex  Avith  which  the  ordinary 
color  of  the  fundus  of  the  eye  was  in  marked  contrast.  The 
choroid  beyond  the  region  of  the  detachment  seemed  to  be  free 
from  any  gross  alteration.  The  optic-nerve  head  was  in  good  con- 
dition, but  was  surrounded  by  a  pronounced  staphyloma. 

As  a  result  of  these  findings,  the  author  certified  that  the 
detachment   of   the   retina  which   he  described  was  certainly   the 


100        Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

cause  of  the  marked  loss  of  the  central  and  peripheral  vision  noted 
above. 

As  to  what  would  be  the  results  of  this  affection  in  the 
future  the  author  stated  that  it  could  not  be  denied  that  detach- 
ment of  the  retina  is  one  of  the  most  serious  of  ocular  lesions. 
The  ordinary  tendency  of  such  a  disease  is  to  be  progressive;  and, 
although  the  condition  is  at  times  stationary,  complete  recovery 
is  very  exceptional.  He  stated  that  since  the  various  treatments 
used  on  V.  had  not  been  able  to  check  the  coui'se  of  tlie  disease  in 
the  slightest  degree,  it  was  to  be  feared  that  the  amount  of  vision 
that  was  present  at  the  time  might  in  tlie  future  undergo  still 
further  diminution. 

As  to  tlie  question  was  the  blow  tliat  was  received  the  only 
cause  for  the  ocular  condition  of  the  claimant,  or  should  the  state 
of  the  eye  be  attributed  to  the  blow  as  well  as  to  any  special  cir- 
cumstances related  to  tlie  general  condition  of  V.,  the  author  as- 
serted that  he  thought  that  he  could  state  that  the  blow  given  by 
D.  Avas  the  direct,  the  immediate,  and  the  determining  cause  of  the 
retinal  detachment  which  had  a  fleeted  the  eye.  Indeed,  before  the 
altercation  and  the  blow  which  followed  it  V.  seemed  to  have  never 
been  troubled  witli  the  vision  of  his  right  eye,  and  as  he  had 
already  lost  the  left  ej^e,  it  must  be  supposed  that  if  any  of  the 
functional  disturbances  had  appeared  wliich  are  so  common  and 
pronounced  in  progressive  myopia  the  claimant  would  have  con- 
sulted an  ophthalmologist;  this  he  had  not  done  since  the  oper- 
ation on  the  fellow-eye  some  six  years  previously.  Moreover,  he 
worked  at  his  profession  until  the  day  before  the  dispute,  and  no 
one  had  ever  suspected  the  slightest  diminution  of  his  vision.  In 
addition,  the  examination  of  the  fundus  of  the  eye  did  not  reveal 
a  trace  of  retinitis,  macular  choroiditis,  tumor,  or  any  gross  lesion 
which  might  have  produced  the  detachment  of  the  retina.  V.  had 
enjoyed  good  health,  his  constitution  was  robust,  and  a  physical 
examination  of  his  principal  organs  showed  that  they  were  in  ex- 
cellent condition.  An  analysis  of  the  urine  as  regards  the  pres- 
ence of  sugar  and  albumin  was  negative. 

As  to  the  query  could  the  myopia  of  about  five  diopters 
which  had  affected  V.'s  right  eye  be  considered  as  liaving  some 
part  in  the  determination  and  the  development  of  the  retinal  de- 
tachment, the  author  decided  that  there  was  no  doubt  that  a 
myopic  eye  is  not  an  absolutely  normal  one,  but  cases  in  which  the 


Traumatic  Lesions  of  the  Eyeball.  l(jl 

disease  is  stationary  must  be  distinguished  from  those  in  which 
the  condition  is  periodically  or  constantly  progressive.  Stationary 
myopia,  of  a  degree  that  is  less  than  six  diopters,  he  believed,  does 
not  generally  present  any  danger,  and  does  not,  as  a  rule,  give 
rise  to  any  serious  lesion  of  the  deep  membranes  or  media  of  tlie 
eye.  Progressive  myopia,  on  the  other  hand,  by  a  series  of  com- 
plications, may  lead  to  loss  of  vision.  V.'s  myopia,  however,  was 
stationary,  and  the  patient  had  arrived  at  an  age  at  which  his 
degree  of  near-sightedness,  except  in  rare  cases,  docs  not  increase. 
Besides,  none  of  the  characteristic  changes  of  progressive  myopia 
(extensive  staphyloma  encroaching  upon  the  macula,  areas  of 
choroidal  atrophy  in  the  same  region,  etc.)  were  visible  in  his 
case.  Consequently  the  author  considered  that  the  claimant's 
myopia  must  be  regarded  as  a  very  slight  factor  in  the  produc- 
tion and  the  development  of  the  retinal  detachment. 

As  a  result  of  this  investigation  the  following  conclusions 
seemed  justifiable: — 

"1.  The  visual  acuity  of  V.'s  right  eye — less  than  one- 
twentieth  of  normal — and  the  suppression  of  a  large  part  of  the 
peripheral  portion  of  the  right  visual  field  do  not  allow  the  claim- 
ant to  walk  alone  with  security,  still  less  to  continue  his  occupa- 
tion. 

"2.  The  present  visual  acuity,  far  from  becoming  better,  will 
in  all  probability  undergo  a  further  diminution. 

"3.  The  present  condition  of  the  eye  is  the  result  of  a  trau- 
matic type  of  detachment  of  the  right  retina,  due  to  a  blow,  re- 
ceived by  V.  on  the  thirtieth  of  September,  189-. 

"4.  The  contused  eye  had  been  affected  by  non-progressive 
myopia  of  a  degree  less  than  six  diopters.  This  condition  could 
only  play  a  comparative  part  in  the  production  and  the  develoj)- 
ment  of  the  retinal  detachment." 

Ordinarily  a  slight  contusion  of  the  eye  gives  rise  to 
only  a  temporary  blurring  of  vision,  which,  as  a  rule,  is 
accompanied  by  a  sensation  of  dazzling.  Generally  pain  is 
quite  insignificant.  When  the  contusion  is  somewhat  more 
intense  in  character,  .the  shock  is  at  times  followed  by 
spasm  of  the  iris,  paralytic  dilatation  of  the  pupil  (irido- 


102        Injuries  to  the  Eye  in  their  Mcdico-leyal  Aspect. 

plegia),  paresis  or  paralysis -of  accommodation,  and  a  slight 
diminution  in  central  and  peripheral  vision.  In  general, 
these  symptoms  rapidly  improve  and  permanently  disap- 
pear. However,  it  is  prudent  in  all  cases,  even  when  there 
is  an  absence  of  any  appreciable  lesions,  to  be  cautious 
about  prognosis,  for  serious  complications  may  ofttimes 
appear  later  (see  section  on  "Shock  of  the  Eetina"). 

A  peculiarity  that  has  been  long  noted,  and  which  the 
author  has  been  able  to  see  recently  verified,  in  the  case  of 
a  young  college  student  who  was  struck  in  the  eye  with 
the  point  of  an  elbow,  is  the  persistence  of  mydriasis,  and 
the  resistance  of  the  iris-tissue  to  the  action  of  eserine. 
As  in  the  case  of  the  two  patients  of  Armaignac,^"^  the 
amplitude  of  accommodation  in  this  case  remained  normal. 
A  case  of  total  separation  of  the  iris,  recently  seen  by  Eene, 
may  be  added,  to  illustrate  that  the  absence  of  the  iris- 
diaphragm  does  not  sensibly  modify  the  function  of  ac- 
commodation.^*'^ 

With  a  greater  degree  of  violence  given  to  the  eye, 
such  as  may  be  received  from  heavy  blunt  bodies,  such 
conditions  as  hemorrhagic  effusion  beneath  the  conjunctiva, 
into  the  anterior  chamber,  and  into  the  vitreous  humor  may 
be  noticed.  Erosions  of  the  corneal  membrane  followed 
by  local  neuralgia,  inflammation,  and  suppuration  may  also 
take  place,  while  lacerations  of  the  iris-tissue,  of  the  cho- 
roid, and  of  the  retina  are  not  infrequent.  Euptures  of 
the  zonule  of  Zinn  and  of  tlie  capsule  of  the  crystalline 
lens,  followed  by  luxation  and  opacification  of  the  lens 
itself,  are  not  of  unusual  occurrence.  Some  of  these  lesions 
may  be  masked  for  quite  a  period  of  time  by  such  condi- 
tions as  hemorrhages  into  the  anterior  chamber  or  vitreous 
chamber  and  opacities  in  the  cr3\stalline  lens.  It  is,  there- 
fore, indispensable  in  all  cases  to  observe  the  symptoms  un- 


TrauiiKitic  Lesions  of  the  Eyeball.  103 

remittingly  for  a  period  of  several  weeks  or  months  before 
attempting  to  formulate  any  definite  opinion  upon  the 
gravity  and  the  consequences  of  any  such  forms  of  trauma- 
tism. 

In  cases  of  violent  contusion — such  as  those  which 
are  caused,  for  example,  by  large  fragments  of  stone  or 
pieces  of  iron,  or  by  blows  from  cows'  horns,  for  example — 
the  eyeball  is  suddenly  compressed,  and  at  times  is  rupt- 
ured, allowing  the  iris,  the  crystalline  lens,  and  a  portion 
of  the  vitreous  humor  to  escape  through  a  large  corneo- 
scleral opening.  It  is  unnecessary  here  to  insist  upon  the 
gravity  of  such  a  condition,  which  is  too  often  rapidly  fol- 
lowed by  an  intense  general  inflammation  of  the  eyeball 
(panophthalmitis),  or  may  terminate  in  bulbar  atrophy 
after  months  of  conservative  treatment.  Immediate  enu- 
cleation is,  as  a  rule,  the  only  resource  in  such  cases. 

The  prognoses  of  the  different  types  of  traumatic  le- 
sions that  have  be^n  cursorily  reviewed  are  most  variable, 
and  have  been  considered  more  at  length  in  the  preceding 
chapters  on  traumatisms  of  the  individual  parts  of  the 
organ. 

The  eyeball  is  sometimes  torn  from  the  orbit  by  the 
thrust,  for  example,  from  a  cows'  horn,  a  heavy  stick,  a  foil, 
or  a  curved  hook.  Usually  tlie  tips  or  ends  of  such  wound- 
ing agents  pass  between  the  bony  walls  of  the  orbit  and 
the  eyeball,  and  act  as  levers,  forcibly  pushing  the  eye  out- 
ward; so  that  the  organ,  suspended  by  the  elongated  optic 
nerve,  the  stretched  muscles,  vessels,  and  other  tissues, 
may  even  protrude  far  forward.  Such  a  form  of  displace- 
ment is  termed  true  luxation.  If  the  muscles  and  the 
optic  nerve  are  torn,  the  condition  is  ordinarily  known  as 
avulsion. 

The  most  serious  complications  may  accompany  these 


104        Injtmes  to  the  Eye  in  their  Medico-legal  Aspect. 

forms  of  lesions:  rupture  of  the  eyeball,  laceration  of  the 
eyelids,  fracture  of  the  orbital  walls,  foreign  bodies  in  the 
orbit,  cerebral  disturbance,  etc.  Nevertheless,  if  the  eye- 
ball is  uninjured,  its  reposition  by  suture  of  the  tendons 
and  conjunctival  mucous  membrane  under  antiseptic  pre- 
cautions is,  at  times,  followed  by  more  or  less  perfect  vision 
and  ocular  movement.  In  general,  however,  prognosis 
should  be  most  cautious,  as  the  eye  may  become  blind  from 
subsequent  attacks  of  retrobulbar  neuritis  and  consequent 
atrophy. 

In  the  case  of  avulsion  or  complete  rupture  of  the 
optic  nerve  it  is  only  necessary  to  complete  the  enucleation. 

Where  workmen  have  been  caught  in  landslides,  in 
which  an  eye  has  been  struck  by  heavy  masses  of  earth  or 
coal  (Gesiier"^),  or  in  cases  where  an  eye  has  been  vio- 
lently contused,  as,  for  example,  by  the  kick  of  a  horse  or 
by  a  blow  from  a  stone,  different  authors^"^  have  observed 
a  sinking  of  the  eyeball  into  the  orbit  (enophthalmos), 
with,  at  times,  a  permanent  more  or  less  complete  loss  of 
vision. 

(b)  wounds  and  bukns  of  the  eyeball. 

Pointed  and  cutting  instruments  frequently  produce 
severe  injuries  of  the  eyeball.  The  author  has  had  abun- 
dant opportunity  of  observing  many  cases  of  penetrating 
wounds  of  the  eye  that  have  been  caused  by  knives,  weavers' 
shuttles,  and  fragments  of  metal.  As  the  eye  in  such  cases 
is  quite  often  lost  by  panophthalmitis  or  an  iridocyclitis, 
he  has  frequently  advised  an  immediate  enucleation  in 
such  cases,  by  which  means  he  has  rid  the  patients  of  long 
periods  of  suffering,  enabling  them  to  return  to  work  much 
earlier  than  if  the  eye  had  been  allowed  to  remain,  and 
removing  almost  all  danger  of  sympathetic  ophthalmia. ^°® 


Traumatic  Lesions  of  the  Eyeball.  105 

When  a  foreign  body  has  not  penetrated  tlie  eyeball, 
but  has  produced  extensive  lacerations,  the  organ,  as  a  rule, 
is  relatively  free  from  infection  and  rarely  gives  rise  to 
sympathetic  disease.  It  must  be  remembered,  however, 
that  large  wounds  of  the  cornea  or  of  the  sclera  may  rap- 
idly heal  without  marked  inflammatory  reaction,  while 
the  organ  itself  may  preserve  almost  its  original  normal 
aspect.^"^ 

The  few  exceptionally-favorable  cases  cannot,  however, 
lessen  the  gravity  of  such  types  of  traumatism.  Indeed, 
when  a  deep  and  an  extensive  wound  involves  the  sclero- 
corneal  region,  the  ciliary  body,  the  choroid,  and  the 
retina,  there  is,  as  a  rule,  an  evacuation  of  the  crystalline 
lens  and  loss  of  the  greater  part  of  the  vitreous  humor.  Jn 
such  cases  irretrievable  damage  to  an  eye  is  almost  in- 
evitable. Sympathetic  disease  is  said  to  be  most  feared 
when  the  wound  becomes  infected,"^  when  the  wound  is 
situated  close  to  the  ciliary  region,  and  when  the  general 
condition  of  the  patient  is  bad. 

Injuries  caused  by  fire-arms  and  certain  types  of  burns 
present  peculiarities  that  are  worthy  of  being  noted. 
Wounds  by  fire-arms  are,  as  a  rule,  produced  by  bullets,  by 
shot,  and  by  deflagration  of  powder.  When  an  eye  is 
struck  by  a  projectile  or  by  a  piece  of  a  splintered  object, 
it  is  generally  disorganized  and  destroyed,  unless,  as  in 
some  instances,  the  wounding  agent  passes  between  it  and 
the  bony  walls  of  the  orlnt.^""  It  has  been  seen  that  com- 
plex lesions — such  as  section  of  the  muscles  and  of  the  optic 
nerve,  enophthalmos — and  frequently  complications — such 
as  fractures  of  the  orbit  and  meningo-encephalitis— may  be 
the  results  of  such  varieties  of  traumatism. 

Sympathetic  disease  is,  according  to  most  statistics,  a 
frequent  complication  of  injuries  of  the  eye  that  have  been 


106        Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

caused  by  projectiles.  The  report  of  Otis,  upon  the  War 
of  the  Eebellion  in  the  United  States  of  America,  gives  a 
proportion  of  about  18  per  cent,  out  of  one  hundred  cases. 
According  to  the  German  documents  relating  to  the  Cam- 
paign of  1870,  more  than  one-half  of  the  ocular  trauma- 
tisms were  followed  by  sympathetic  symptoms.  In  this 
study,  penetrating  wounds  that  were  complicated  by  the 
presence  of  foreign  bodies  gave  evidences  of  this  disease  in 
80  per  cent,  of  the  total  number  of  cases,  while  complete 
or  incomplete  loss  of  the  organ  of  sight  occurred  in  G2.7 
per  cent.^^° 

While  Delorme  {loco  citato)  doubts  that  a  column  of 
air  set  in  rapid  motion  by  a  projectile  can  produce  a  shock 
of  the  retina,  nevertheless  observations  have  proved  that 
an  eyeball  may  be  injured  by  the  detonation  of  projected 
masses  of  large  calibre.  Legues  has  recently  reported  the 
case  of  an  artilleryman  who,  while  firing  a  piece  of  arma- 
ment of  nineteen  centimeters'  calibre,  felt  a  violent  shock 
and  an  acute  pain  in  his  right  eye,  the  sight  in  which  was 
immediately  lost.  Examination  showed  that  there  was  an 
extensive  hemorrhage  in  the  vitreous  humor,  while  the  cor- 
nea, the  anterior  chamber,  and  the  crystalline  lens  were 
found  to  be  intact."^ 

The  explosion  of  powder  in  the  vicinity  of  an  eye 
l)urns  and  injures  the  organ  superficially^^-  or  deeply  in 
accordance  with  the  composition  of  the  material  and  the 
position  and  the  distance  of  the  eye  from  the  point  of 
explosion.  Powder  ignites  at  quite  a  high  temperature  and 
the  burns  that  are  produced  are  caused  both  by  the  gases 
til  at  are  developed  and  by  incandescent  grains  of  carbon. 
The  grains  are  of  a  coarser  size  in  mine-powder  than  they 
are  in  gunpowder,  and,  in  consequence,  undergo  a  less 
complete  combustion.    Both  kinds  of  powder  thus  play  the 


TrainiKitic  Lesions  of  the  EychaU.  107 

part  of  true  foreign  bodies  and  produce  a  most  marked 
tattooing;  sometimes  without  inflammatory  reaction,  but 
more  frequently  complicated  by  minute  corneal  and  pal- 
pebral abscesses.  At  times  there  may  be  an  obstinate  in- 
flammation of  the  conjunctiva  and  the  cornea,  or  even  of 
the  iris,  which  may  prevent  a  patient  from  resuming 
work  for  several  months'  time.  The  amount  of  singeing  of 
the  eyebrows,  and  the  hair  of  the  head,  as  well  as  the  pres- 
ence of  whitish  zones  surrounding  the  incrustations  in  a 
bloodshot  and  inflamed  conjunctiva,  often  enable  the  sur- 
geon approximately  to  determine  the  distance  and  the 
direction  of  the  patient  from  the  point  of  explosion. ^^" 

In  other  cases  grains  of  powder  propelled  by  a  greater 
velocity  may  pass  through  the  corneal,  the  scleral,  and  the 
iris  tissues,  and  lodge  in  the  crystalline  lens,  giving  rise  to 
a  traumatic  cataract.  They  may  also  act  as  foreign  bodies 
in  the  media  or  the  deep  membranes  of  the  eye,  and  become 
the  starting-points  of  serious  inflammatory  processes  that 
may  end  in  phthisis  bulbi,  with  blindness.  Recovery  of 
such  cases  has  been  reported,  as,  for  example,  by  Oliver^^*; 
so  that  this  favorable  result  should  not  be  overlooked. 

Multiple  traumatic  lesions — as,  for  example,  lacera- 
tions and  wounds  of  the  eyelids,  perforation  of  the  ocular 
membranes,  and  cataract — that  are  produced  hy  the  gases 
which  are  evolved  in  tlie  deflagration  of  gunpowder  make 
the  results  of  the  immediate  type  of  burns  by  this  agent 
of  secondary  importance.  Out  of  seventy-five  cases  of  in- 
juries of  this  kind,  de  Bovis  {loco  citato)  noted  blindness 
of  one  eye  in  twenty-eight  instances  and  of  both  eyes  in 
three.  In  an  analogous  type  of  case  the  author  succeeded 
in  preserving  a  satisfactory  degree  of  visual  acuity  in  one 
eye,  though  the  other  one  was  lost. 


108        Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

Case  XVI  (personal  and  unpublished).  —  Powder  -  burns. 
Penetrating  wounds  of  the  left  cornea,  with  hernia  of  the  iris  and 
traumatic  cataract.  Multiple  penetrating  wounds  of  the  riglit  eye: 
enucleation  of  the  right  eye.  Cataract  operation  on  the  left  eye: 
recoA^ery  with  satisfactory  visual  acuity. 

A.  L.,  a  26-year-old  quarryman,  was  injured  on  the  twenty- 
seventh  of  October,  189-,  by  an  explosion  of  powder  while  charging 
a  blast.  He  was  under  medical  advice  for  about  a  week's  time 
when  he  was  sent  to  the  author. 

At  the  time  of  the  first  examination  it  was  found  that  there 
were  numerous  powder-grain  incrustations  in  the  skin  of  the  fore- 
head, the  face,  and  eyelids,  especially  on  the  right  side.  The  eye- 
lids, which  were  reddened  and  swelled,  could  only  be  opened  with 
the  greatest  difficulty.  The  patient  complained  of  severe  pain  in 
both  eyes  and  in  the  supraorbital  regions. 

There  was  a  marked  chemosis  of  the  right  bulbar  conjunctiva. 
A  wound  of  about  four  millimeters  in  length  located  in  the  sclero- 
corneal  region  could  be  seen  below  and  to  the  nasal  side  of  the 
globe.  A  smaller  wound,  involving  the  cornea  alone,  was  situated 
several  millimeters  above  the  first.  The  corneal  tissue  was  almost 
entirely  infiltrated  with  pus. 

The  lids  of  the  left  eye  were  less  edematous  than  those  of  the 
opposite  side.  The  palpebral  edges  were  agglutinated  by  a  slight 
amount  of  muco-purulent  matter.  The  conjunctival  membrane  was 
moderately  injected  and  was  pigmented  with  carbon-grains,  espe- 
cially in  its  inferior  portion.  The  lower  third  of  the  cornea  and  the 
sclera  in  the  corresponding  portion  were  tattooed  with  grains  of 
burnt  poA\der.  At  the  external  portion  of  the  cornea  there  was  a 
penetrating  wound  that  was  about  three  millimeters  in  length, 
between  the  lips  of  Avhich  the  iris  was  partially  prolapsed.  There 
was  a  traumatic  cataract. 

On  the  fourth  of  November,  after  a  careful  examination  of 
the  patient,  in  association  with  Coppez,  the  surgeon  for  an  insur- 
ance company,  it  was  decided  to  chloroform  the  patient  and  to 
enucleate  the  left  eye.  This  was  done.  The  corneal  wound  healed 
and  the  hernia  of  the  iris  was  reduced.  Sixteen  days  later  an  iri- 
dectomy was  done  on  the  right  eye,  the  jiatient  being  allowed  to  re- 
turn home  for  about  a  month's  time.  On  the  twenty-seventh  of 
December  the  cataraetous  lens  was  extracted.    In  two  weeks'  time 


Traumatic  Lesions  of  the  Eyeball.  109 

the  eye  permanently  recovered,  a  convex  spherical  lens  of  ten 
diopters'  strength  giving  a  visual  acuity  that  equaled  one-half  of 
normal. 

Traumatic  lesions  produced  by  tlie  explosion  of  pow- 
der, of  fire-damp,  and  of  dynamite,  or  by  various  chem- 
icals"^ and  by  electrical  discharges  can  be  now  considered. 
This  class  of  injuries,  which  naturally  presents  a  great 
variety  of  lesions,  is,  as  a  rule,  produced  by  the  projection 
of  small  aseptic  particles,  such  as  glass,  fragments  of  retorts 
and  receivers,  pieces  of  stone,  and  debris  of  all  kind. 
Often,  owing  to  the  involuntary  closure  of  the  eyelids,  the 
burns  of  the  eyeball  itself  are  superficial.  So  likewise  dur- 
ing explosions  of  boilers^^*'  and  steam-pipes  the  eyes  fre- 
quently partly  escape  the  action  of  the  steam  itself  in  a 
similar  manner.  Yon  Hippel,^^'  out  of  forty  cases  of  in- 
juries due  to  explosions  of  dynamite,  has  reported  twenty- 
one  instances  of  loss  of  one  eye  and  seven  cases  of  loss  of 
both  eyes.  Subconjunctival  hemorrhages,  opacities  of  the 
cornea,  and  superficial  burns  of  the  ocular  envelopes  are 
among  the  most  common  conditions.  Eivers's  patient,  who 
received  a  discharge  of  five  hundred  and  fifty  volts  (and 
one  thousand  amperes),  had  a  deep  burn  of  the  face,  and 
lost  consciousness.  The  lesions  of  the  cornea  and  of  the 
conjunctiva  in  this  case  were  slight,  but  photophobia  with 
rapid  fatigue  of  vision  persisted  for  some  time  after  the 
accident. ^^^ 


PAET  THIRD. 


CHAPTEE  I. 

Simulated  or  Exaggeeated  Affections 
OF  THE  Eye.^^** 

In  another  publication^-''  the  author  has  stated  that 
simulation  belongs  to  all  ages,  and  constitutes — so  to  speak 
— one  of  the  attributes  of  the  human  race.  In  fact,  indi- 
viduals are  seen  every  day  trying,  l:)y  many  more  or  less 
ingenious  plans,  either  to  avoid  necessary  obligations,  such 
as  military  service,  for  example,  or  to  escape  certain  social 
duties,  or,  more  frequently,  to  exaggerate  the  consequences 
of  traumatism  in  order  that  they  may  be  able  to  claim 
higher  grades  of  damages.  Some  subjects  who  are  without 
resources  and  are  unwilling  to  work,  at  times  assert  a  com- 
plete amaurosis  so  that  they  may  be  able  to  obtain  pen- 
sions or  gain  admission  into  charitable  institutions.  Again, 
especially  the  nervous  and  the  hysterical  types,  as  one  of 
the  results  of  disappointment,  vengeance,  fantasy,  etc., 
claim  that  they  have  become  suddenly  and  completely 
blind,  or  else  provoke  and  continue  some  form  of  inflam- 
mation of  the  external  membranes  of  the  eye.  Moreover, 
children  who  find  school-life  irksome  not  infrequently  com- 
plain of  fictitious  visual  troubles. 

The  author,  as  ophthalmic  surgeon  to  the  Board  of 
Charities  of  the  City  of  Lille,  is  often  called  upon  to  ex- 
amine the  poor  who  solicit  the  aid  of  money  that  is  appro- 
priated for  the  relief  of  the  blind  and  the  partlv  blind.    In 

(110) 


Simulated  Affections  of  the  Eye.  \w 

this  capiacity  he  has  frequently  noticed  how  often  the  best 
measures  of  charity  that  are  made  in  favor  of  tlie  needy 
run  counter  to  the  luimanitarian  end  that  has  been  held 
in  view.  Some  years  ago  a  considerable  number  of  indi- 
viduals intentionally  neglected  to  consult  their  medical  spe- 
cialist, while  others  refused  to  follow  courses  of  treatment 
which,  though  intended  to  lead  them  to  recovery,  would 
have  deprived  them  of  all  monthly  income.  Force  of  cir- 
cumstances have  led  the  administration  to  refuse  financial 
aid  to  the  so-called  "half-blind,"  since  which  time  the  ever- 
increasing  crowd  of  claimants  for  charity  at  the  author's 
clinic  has  given  place  to  patients  wlin  are  anxious  to  be 
cared  for  and  to  recover. 

"Workmen,"  as  Meden  has  stated,  "do  not  consider 
the  indemnity  which  is  given  to  them  as  an  adequate  com- 
pensation for  the  injury  that  has  been  sustained.  They 
strive  to  increase  their  resources  by  means  of  the  accident 
that  has  happened  to  them.  To  this  end  they  at  times 
endeavor  to  retard  their  recovery  for  long  periods  of  time, 
in  order  that  the  importance  of  an  injury  may  be  increased. 
Again,  they  often  exaggerate  the  magnitude  of  the  slightest 
symptoms,  and  frequently  feign  the  existence  of  visual 
troubles  that  are  not  present. 

"Thus,  for  example,"  he  says,  "since  the  promulgation 
of  the  insurance  laws  of  1884,  an  increase  of  25  per  cent, 
in  the  number  of  cases  of  disease  that  are  due  to  accidents 
has  been  noted  in  the  one  district  of  Saarbriick,  while  the 
ratio  of  the  period  of  duration  of  treatment  in  such  cases 
has  increased  some  30  per  cent.,  the  number  of  cases  of 
ordinary  affections  having  remained  exactly  the  same.''^-^ 

Among  the  diseases  that  patients  feign  in  order  to  be 
adjudged  absolutely  incapable  of  work  affections  of  the  eye 
have  always  held  an  important  place.    This,  in  measure,  is 


112        Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

so  because  slight  lesions  of  the  visual  apparatus  often  con- 
stitute the  most  important  of  the  serious  obstacles  to  the 
exercise  of  a  great  number  of  professions.  It  is  necessary, 
therefore,  that  the  medical  expert  should  know  liow  to 
detect  malingering. 

In  the  present  condition  of  the  science  and  art  of  med- 
icine there  are  a  number  of  methods  of  making  an  almost 
certain  diagnosis  and  of  relieving  pain. 

On  the  other  hand,  care  must  be  taken  not  to  pass  to 
the  extreme  of  considering  every  patient  a  malingerer, 
while  too  much  prudence  and  discretion  cannot  be  exer- 
cised in  the  employment  of  tests  during  the  examination  of 
a  patient.  The  difficulty  of  detection  is  greater  when  the 
degree  of  visual  impairment  must  be  determined  among 
skillful  pretenders  who  have  had  long  experience  or  whose 
acuity  of  vision  in  one  eye  differs  markedly  from  that  in 
the  other.  On  the  contrary,  the  task  of  the  medical  expert 
is  comparatively  easy  when  he  is  dealing  with  ignorant  sub- 
jects, because,  in  this  type  of  cases,  the  complained-of 
troubles  are  not,  as  a  rule,  at  all  proportional  to  the  degree 
and  the  character  of  the  ol)Jective  symptoms.  Thus,  for 
example,  some  types  of  patient  may  declare  that  they  can- 
not distinguish  daylight  from  darkness  when  the  reactions 
of  the  irides  are  absolutely  normal.  Again,  such  individuals 
may  assert  that  the  local  manifestations  of  general  disease 
are  due  to  accidents,  shock,  etc. 

Simulated  and  exaggerated  disorders  of  the  eye  are 
numberless.  In  this  chapter  only  the  principal  affections 
that  are  simulated  at  the  time  of  a  real  or  a  supposed  trau- 
matism of  the  eye  or  of  a  more  distant  region  will  be  con- 
sidered. Moreover,  it  will  be  impossible  in  the  scope  of 
the  present  work  to  make  more  than  a  cursory  study  of 
the  differential  diagnosis  between  such  disorders. 


Himnlated  Affect  ions  of  the  Eye.  H3 

Twice  only  lias  the  author  had  occasion  to  ohserve  a 
simulated  form  of  a  coiijunctivitis.  In  one  case  the  condi- 
tion was  provoked  and  maintained  hy  ttic  instillation  of  a 
strong  solution  of  sui[)hate  of  copper,  and  in  the  other  it 
was  obtained  by  the  introduction  of  the  ashes  of  ordinary 
smoking  tobacco.  These  two  patients  were  not  inclined  to 
work;  they  were  insured  against  accidents,  and  they  were, 
moreover,  members  of  a  society  for  mutual  aid.  The 
reasons  can  l)e  Ijetter  understood  wlicn  it  is  considered  that 
the  benefits  they  received  from  these  sources  of  revenue 
were  greater  than  the  amounts  they  could  have  obtained 
from  their  legitimate  wages.  In  consequence,  they  did 
their  best  to  prolong  an  affection  which  enabled  them  to 
live  without  work. 

For  the  purpose  of  producing  inflammation  of  the  eye, 
malingerers  often  introduce  foreign  bodies,  chemical  agents, 
and  other  irritants  into  their  conjunctival  cul-de-sacs.  The 
substances  most  frequently  employed  are  fine  particles  of 
sand,  grains  of  powder,  bits  of  ash,  tobacco- juice  or  euphor- 
binm-juice,  turpentine,  lime,  corrosive-sublimate  powder, 
sulphate  of  copper,  lemon-juice,  and  urine.  Some  of  these 
materials  give  rise  to  merely  an  hyperemia,  without  hyper- 
secretion. Others  are  more  violent  in  their  action  and  pro- 
duce a  true  conjunctivitis,  which  is  characterized  by  epi- 
thelial desquamation. 

In  such  a  condition,  particularly  of  monocular  and 
rebellious  type  which  without  any  apparent  reason  becomes 
worse  suddenly  and  in  a  subject  whose  interests  tend  to 
lead  him  to  practice  deception,  a  detailed  examination  of 
the  conjunctival  membrane,  particularly  of  the  upper  cul- 
de-sac,  should  be  carefully  made,  in  order  to  determine  the 
presence  of  foreign  bodies  or  to  discover  the  traces  of  sub- 
stances that  may  have  been  purposely  introduced.    In  some 


11-i         Injuries  to  the  Fajc  in  their  Medico-legal  Aspect. 

cases  it  may  be  advisable  to  apply  an  occlusive  bandage  and 
keep  a  strict  watcli  npon  the  patient's  movements  so  that 
he  may  not  be  able  to  continue  any  imposture. 

Much  more  frequently,  workmen,  who  have  such  a 
condition  as  granular  conjunctivitis  or  some  other  type  of 
chronic  lesion  of  the  external  membranes  of  the  eye,  en- 
deavor to  refer  the  long-standing  condition  to  a  recent 
accident.  Similar  attempts  arc  quite  often  made  even  in 
simple  cases  of  ordinary  catarrhal  conjunctivitis,  or  kera- 
titis, particularly  wlien  the  patient  is  insured  against  acci- 
dents. 

In  most  cases  in  which  a  traumatism  affects  the  eye 
of  a  patient  who  is  suffering  from  such  a  condition  as  con- 
junctivitis or  a  conjunctivitis  of  lacrymal  origin,  there  is, 
as  a  rule,  produced  so  slight  an  increase  in  the  previous 
pathological  condition  that  there  can  be  but  little  doubt 
in  each  individual  case  as  to  tlie  probable  degree  of  the 
severity  of  the  injury  itself.  On  the  contrary,  a  conjunc- 
tivitis tliat  is  symptomatic  of  a  wound,  a  burn,  or  the  pres- 
ence of  a  foreign  body  in  the  conjunctival  membrane,  is 
usually  sufficiently  characterized  in  its  principal  symptoms 
to  give  it  a  special  symptomatology  which  is  more  or  less 
certain  as  regards  the  nature  and  the  type  of  the  injury. 

The  question  has  often  been  asked:  can  the  simple 
forms  of  traumatic  conjunctivitis  following  the  introduc- 
tion of  irritant  materials  into  the  conjunctival  sac  be  dif- 
ferentiated from  the  catarrhal  types  of  supposed  sponta- 
neous origin?  It  has  been  shown  tliat,  as  a  rule,  the  special 
signs  of  traumatic  conjunctivitis  are  a  tendency  to  localiza- 
tion of  the  objective  symptoms,  a  speedy  recovery,  and  the 
failure  of  the  plans  of  treatment  that  are  usually  found  to 
be  efficacious  in  the  idiopathic  forms  of  catarrhal  conjunc- 
tivitis.   In  general,  however,  it  must  be  acknowledged  that 


iSlmulatcO  Affevtioits  of  the  Kye.  2.15 

the  distinction  is  quite  ditfieult.  Tlie  history  of  the  case  is 
of  the  greatest  importance;  hut,  as  it  is  so  frequently  falsi- 
fied hy  such  patitMits,  tlie  diagnosis  quite  often  hecomes 
very- uncertain. 

In  the  study  of  burns  of  tlic  cornea  and  the  conjunc- 
tiva it  is  most  difficult  to  determine  the  exact  nature  of  the 
caustic  agent  tlmt  has  caused  the  injury,  particularly  if 
the  history  of  the  case  be  wanting.  Especially  is  this  true 
unless  there  are  superficial  incrustations  of  the  burnt  mate- 
rial, peculiarities  of  burns  of  the  eyelids  and  of  the  face, 
and  characteristic  spots  upon  the  clothing. 

Traumatic  pterygium,  or  false  pterygium,  as  it  is 
sometimes  called,  is  very  often  associated  with  symbleph- 
aron.  Usually  it  appears  as  the  result  of  a  cicatricial  con- 
traction of  the  conjunctiva  following  a  loss  of  conjunctival 
substance  from  a  wound  or  a  burn  which  has  involved 
both  the  cornea  and  an  adjacent  part  of  the  conjunctiva. 
According  to  Fuchs,^--  it  is  quite  easy  to  distinguish  tbis 
form  from  the  so-called  true  pterygium.  The  former  type 
is  located  indifferently  above  or  below  the  corneal  margin 
in  accordance  with  the  position  of  the  area  of  the  desqua- 
mation, the  apex  of  the  growth  being  truncated  and  it 
remaining  stationary  when  it  has  once  become  definitely 
organized. 

It  can  be  well  understood  how  easy  it  is  for  certain 
types  of  workmen  who  are  subjects  of  rheumatic,  syph- 
ilitic, albuminuric,  or  diabetic  dyscrasia  to  associate  any 
slight  form  of  ocular  traumatism  or  inflammation  with 
the  effects  of  a  SA'stemic  condition  such  as  an  iridocho- 
roiditis  or  a  retinochoroiditis,  particularly  when  the  organ 
is  suddenly  affected.  Moreover,  in  general  pathology  there 
is  a  current  belief  that  contusions  predispose  all  organs  and 
tissues  to   inflammatory   processes.      On  the   other  hand, 


WQ         Injuries  Id  IIiv  Eye  in  llieir  Metlieo-hijal  Asijccl. 

Yeneiiil  and  others  have  distinctly  shown  the  incontestahle 
influence  of  traumatism  in  awakening  constitutional  and 
diathetic  conditions.  For  example,  this  can  l)e  distinctly 
seen  in  a  contusion  of  the  eye])all  in  a  rheumatic  suhject 
which  has  suddenly  become  worse  without  any  apparent 
reason.  The  injury  should  l)e  looked  upon  as  the  exciting 
cause  of  a  condition  which  is  the  result  of  the  dyscrasia. 

Hemorrhages  into  the  anterior  chamber,  the  retina, 
the  choroid,  and  vitreous  humor  cannot,  as  a  rule,  be  con- 
sidered of  traumatic  oi'igin  unless  the  cause  has  ])een 
elicited  by  a  process  of  strict  exclusion.  Eecent  and  in- 
dubitable evidence  of  lesions  of  the  orbital  margin  or  of 
the  external  coats  of  the  eyeball  itself  must  in  most  cases 
be  shown,  while  general  and  local  affections — such  as  are 
ordinarily  produced  by  diseases  of  the  circulatory  and  the 
respiratory  systems:  for  example,  dysmenorrhea,  meno- 
pause, chlorosis,  anemia,  gout,  rheumatism,  diabetes,  and 
albuminuria;  as  well  as  purely  local  conditions,  such  as 
glaucoma,  iridochoroiditis,  and  high  myopia — must  all  be 
eliminated. 

Since  traumatic  cataract  is,  in  general,  the  result  of  a 
direct  form  of  injury  to  the  crystalline  lens  by  a  body  that 
has  perforated  the  cornea  and  the  iris,  or  the  cornea  alone, 
an  examination  with  oblique  illumination  will  often  be  of 
assistance  in  making  an  etiological  diagnosis.  This  is  done 
by  revealing,  according  to  the  date  of  the  accident,  of 
either  a  simple  or  an  adherent  form  of  leucoma,  a  recent 
or  an  old  wound  of  the  cornea,  a  laceration  or  a  detachment 
of  the  iris-tissue,  or  the  presence  of  a  foreign  body  in  the 
cortical  layers  of  the  lens  itself. 

Cataract  that  is  supposed  to  be  due  to  a  shock  of  the 
lens  often  has  the  appearance  of  a  spontaneous  form  of 
opacity.     This  is  so  on  account  of  the  slowness  of  its 


tiimnJated  Affections  of  the  Ei/r.  j^j^ij' 

growth.  This  fact  frequently  enables  a  malingerer  to  en- 
deavor to  attribute  a  constitutional  type  or  a  symptomatic 
form  of  cataract  to  a  contusion  of  the  ej'eball,  to  a  shock 
of  the  head,  or  to  a  fall  upon  the  feet;  in  brief,  to  a  sup- 
posed related  form  of  traumatism. 

Systemic  forms  of  cataract,  such  as  are  seen  in  dia- 
betes, or  those  tliat  are  simply  exj)ressive  of  such  local  con- 
ditions as  chorioretinitis,  retinal  detachment,  glaucoma, 
and  intraocular  tumor  usually  have  sufficiently  character- 
istic general  and  local  signs  that  are  diagnostic;  so  that  the 
complainant  can  rarely  deceive  the  observer. 

Congenital  cataract  exists  from  earliest  infancv,  and  is 
generally  found  in  both  eyes. 

The  question  of  determining  wliether  certain  types  of 
displacements  of  the  crystalline  lens  without  any  apparent 
rupture  of  the  ocular  membranes  are  of  traumatic  origin 
or  not  is  of  great  importance  in  legal  medicine. 

In  the  first  case,  if  the  luxation  is  exclusively  the  re- 
sult of  the  action  of  some  projectile  or  of  a  violent  blow  in 
the  orljital  region,  the  most  careful  examination  made  im- 
mediately after  the  accident  does  not,  as  a  rule,  show  any 
trace  of  previous  affection  in  either  eye,  the  displaced  lens 
nearly  always  preserving  its  transparency.  In  such  a  case 
the  trauuuitism  is  most  |)robal)ly  the  sole  cause  of  the 
condition. 

AVhcn,  however,  a  chronic  form  of  inflammation  of 
the  uveal  tract  is  followed  liy  a  contraction  of  the  vitreous 
humor,  altering  the  suspensory  ligament  of  the  crystalline 
lens  and  disturbing  the  relationship  between  the  aqueous 
humor  alid  the  vitreous  humor,  the  slightest  shock  may  be 
sufficient  to  displace  the  crystalline  lens.  In  such  a  case  a 
medical  expert  may  not,  as  a  rule,  hesitate  to  state  that  the 
traumatism  has  been  the  immediate  cause  of  a  lesion  to 


118        Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

which  the  eye  has  been  predisposed  h}^  reason  of  a  previous 
pathological  condition. 

When  a  detachment  of  the  retina  is  accompanied  by 
subretinal  hemorrhages  and  extravasations  of  blood  into 
the  vitreons  chamber  associated  with  evidences  of  contusion 
upon  the  lids  or  eyeball  in  an  eye  that  does  not  present  any 
gross  symptoms  of  local  or  systemic  type,  it  may  be  safely 
concluded  that  the  cause  of  the  detachment  of  the  retina 
has  been  traum'atic  in  character. 

Of  all  the  feigned  diseases  of  the  eye,  the  most  frequent 
ones  are  unilateral  amaurosis  and  amblyopia.  The  simu- 
lator^the  victim  of  an  accident,  for  example — states  that 
he  is  unable  to  see  witli  one  eye,  or  exaggerates  a  true 
weakness  of  vision  which  has  existed  l)efore  the  accident, 
declaring— for  instance^that  lie  can  see  only  well  enough 
to  walk  alone,  liut  not  enough  to  work.  In  such  a  case  the 
medical  expert  will  be  compelled  to  solve  the  three  follow- 
ing questions:  1.  Is  the  unilateral  amaurosis  or  amblyopia 
real?  If  there  is  an  amblyopia,  what  is  its  degree?  2.  Is 
the  amaurosis  or  tlic  amblyopia  of  traumatic  origin?  3. 
Will  the  more  or  less  marked  weakening  of  vision  remain 
stationary;  will  it  end  in  recovery  or  will  it  terminate  in 
blindness  ? 

As  illustrative,  let  it  be  supposed,  in  the  following 
description  of  the  various  methods  that  are  employed,  that 
the  right  eve  is  the  one  that  is  assumed  to  be  affected. 

After  it  has  been  made  fairly  certain  that  the  ambly- 
opia or  the  amaurosis  cannot  be  explained  by  a  lesion  of 
the  central  nervous  apparatus,  by  disturbances  in  the  trans- 
parency of  the  intraocular  media,  or  by  errors  of  refrac- 
tion, the  condition  of  the  pupil  and  the  direction  of  the 
visual  axes  should  be  determined.    . 


Simulated  Affections  of  the  Eye.  ng 

(a)  objective  methods. 

1.  Condition  of  the  pupil. ^'^  If  the  right  eye  is  am- 
aurotic and  the  retina  is  no  hunger  sensitive  to  light- 
stimuhis  thrown  npon  it  (the  left  eye  being  covered  in 
such  a  way  that  it  can  he  ohserved)^  it  will  be  found  that 
there  is  complete  immobility  not  only  of  the  iris  of  the 
right  eye,  but  also  of  that  of  the  left  eye. 

Under  such  circumstances,  while  the  subject  is  in  a 
darkened  room  the  supposed  amaurotic  right  eye  is  to  be 
covered  in  such  a  way  that  it  can  be  watched.  This  done, 
a  beam  of  light  is  to  be  thrown  upon  the  (good)  left  eye, 
varying  the  intensity  of  the  illumination.  This  is  to  be 
followed  by  having  the  left  eye  fix  upon  an  object  that  is 
placed  directly  ahead  close  to  it  and  then  to  the  nasal  side. 
During  these  tests  the  pupil  of  the  right  eye  will  ordinarily 
contract. 

The  first  of  these  results,  hoAvever,  becomes  doubtful 
if  the  affected  eye  possesses  quantitative  degrees  of  light- 
perception,  rendering  an  opinion  uncertain,  with  a  possi- 
bility of  error  against  the  patient.  It  is  best  in  all  cases 
to  repeatedly  employ  several  tests;  the  one  controlling  the 
other.  If  an  eye  possess  a  normal  amount  of  visual  acuity 
with  pupillary  dilatation,  frequently  it  presents  functional 
disturbances  that  are  due  to  so-called  dazzling,  and,  as  a 
rule,  will  generally  be  found  to  have  lost  its  power  of 
accommodation.  The  method  of  arriving  at  a  differential 
diagnosis  in  such  cases  is  as  follows:  The  patient  is  to  be 
placed  in  a  darkened  room.  Xotice  is  then  to  be  made 
particularly  of  the  degree  of  contraction  of  the  sphincter- 
muscle  of  the  iris  of  the  healthy  eye.  This  eye  is  covered 
and  a  strong  light-stimulus  (best  obtained  by  the  aid  of 
a  convex  lens)  is  projected  upon  the  eye  in  Avhich  the 


120         Injuries  to  the  Eye  in  their  Medico-Uyal  Aspect. 

mydriasis  is  present.  If  the  retina  of  tlie  bad  eye  is  insen- 
sitive, the  pupil  of  the  good  one  will  not  vary  in  size.  If 
the  bad  eye  is  merely  amblyopic,  its  iris  will  react  slowly 
and  slightW,  while  that  of  the  fellow-eye  may  be  quite 
active.  If  the  visual  acuity  and  the  accommodative  power 
of  the  supposed  bad  e3'e  is  normal,  the  contraction  of  its 
iris  when  the  light-stimulus  is  thrown  upon  its  retina  will 
be  as  pronounced  as  if  the  pencil  of  light  had  been  pro- 
jected directly  upon  the  good  eye. 

Artificial  mydriasis  is  often  produced  for  the  purpose 
of  shamming,  and  the  medical  expert  should  endeavor  not 
to  be  deceived  by  it.  In  such  cases  the  pupil  is,  as  a  rule, 
dilated  practically  to  its  maximum  degree.  At  times  a  slight 
conjunctivitis  due  to  the  prolonged  use  of  the  drug  may 
be  present.  When,  however,  a  pretender  is  familiar  with 
the  effects  of  mydriatics,  he  generally  employs  a  small  quan- 
tity of  the  drug  and  discontinues  its  use  some  time  before 
an  examination  is  made  in  order  to  obtain  but  a  moderate 
degree  of  pupillary  dilatation.  In  such  uncertain  cases 
doubt  is  always  admissible,  and  it  must  be  seen  that  such 
a  pretender  does  not  have  any  access  to  such  drugs. 

In  cases  of  artificial  monocular  mydriasis  excitation  of 
either  retina  does  not  produce  any  contraction  of  the  dilated 
pupil. 

An  examination  of  the  iris  and  of  tlie  pupil  is  impor- 
tant in  all  cases,  although,  as  before  shown,  such  a  study 
does  not  enable  tlie  physician  to  determine  positively  the 
absolute  condition  of  the  retina. 

In  cases  of  supposed  monocular  amblyopia  the  exam- 
ination of  the  iris  and  the  pu])il  will  give  much  less  definite 
information  than  when  simulation  of  unilateral  amaurosis 
is  being  sought  for.  An  amblyopic  eye  always  possesses  a 
quantitative  degree  of  perceptive  power.     Unless,  there- 


Simulated  Affections  of  IJic  Eye.  ^2^ 

iore,  there  is  a  true  mydria.sis,  a  more  or  less  movement  of 
the  iris  as  compared  witli  that  ot  the  iris  of  the  pro- 
nouncedly sound  eye  will  l)e  i'oimd.  It  may  he  easily  un- 
derstood. Iiowevei'.  that  ilio  diU'ereuces  of  reaction  will  often 
be  very  slight^  and  that  their  interpretation  is  quite  fre- 
quently both  changeable  and  uncertain. 

2.  Direction  of  the  visual  axes.  In  normal  binocular 
vision  the  visual  axes  converge  in  such  a  way  as  to  allow 
their  ends  to  meet  upon  any  fixed  object  that  makes  an 
impression  upon  identical  points  of  the  two  retinas;  that 
is  to  say,  upon  the  fovea  centrales.  Differences  in  the 
directions  of  the  visual  axes,  however,  result  from  paral- 
ysis. ]iaresis,  contraction,  and  spasm  of  one  or  more  of  the 
ocular  luuscles.  Such  affections  fortunately  are  very  dif- 
ficult and  ofttimes  impossible  to  simulate  during  prolonged 
examinations.  Acute  paralytic  strabismus  most  frequently 
co-exists  with  a  normal  degree  of  vision.  Moreover,  it  is 
often  transient  and  curable.  In  the  chronic  type,  how- 
ever, it  is,  as  a  rule,  accompanied  with  a  diminution  of 
visual  acuity  or  even  with  a  true  l)lindness.  The  same  is 
true  in  tlie  functional  forms  of  strabismus,  which,  though 
often  associated  with  an  anomaly  of  refraction,  are  at  times 
found  to  be  consecutive  to  an  amblyopia  or  an  amaurosis. 

In  all  sucli  cases  the  medical  expert  should  make  a 
most  careful  examination,  and  have  recourse  to  all  the 
means  of  investigation  that  may  be  at  his  command.  In 
addition,  he  should  base  his  opinion  upon  repeated  tests, 
the  value  and  results  of  which  cannot  be  questioned.  In- 
deed, an  inditl'erent  nv  an  ignorant  observer  may  be  easily 
baffled,  for  a  patient  who  is  affected  with  strabismus,  for 
example,  frequently  has  the  faculty  of  disregarding  an 
image  that  is  perceived  by  an  eye  which  he  claims  to  be 
amaurotic. 


123        Injuries  to  the  Eye  in  their  Medico-Jegal  Aspect. 

In  addition  to  the  evidences  that  are  furnished  by 
objective  observations,  there  are  various  subjective  methods 
which  can  be  employed  for  the  detection  of  simulation. 
In  this  work  the  author  will  limit  himself  to  the  task  of 
explaining-  only  the  most  sim})le  and  the  most  practical  of 
the  tests  that  are  used  for  the  purpose,  some  of  which 
merely  expose  the  dishonesty  of  a  subject,  while  others 
give  data  that  enable  the  observer  to  determine  quite  ac- 
curately the  actual  amount  of  visual  acuity  that  is  pos- 
sessed by  the  examinee. 

(b)  sub.jective  methods. 

A  great  number  of  subjective  methods  exist.  These, 
as  a  rule,  are  dependent  upon  the  properties  of  lenses,  mir- 
rors, and  prisms  (Harlan,^-*  Javal,  Snellen,  and  others). 
In  these  tests  the  patient  is  made  to  read  characters  with 
the  supposedly-amaurotic  eye  which  the  sound  eye  is  ap- 
parently gazing  at,  but  which,  by  the  aid  of  various  con- 
trivances, it  cannot  distinguish. 

In  most  all  of  these  tests  it  is  taken  for  granted  that 
the  medical  expert  is  placed  in  such  a  position  as  to  be 
aljle  to  watch  that  the  patient  does  not  close  one  or  the 
other  of  his  eyes. 

Among  the  best-known  plans  the  following  may  be 
noted: — 

1.  A  convex  spherical  lens  of  about  sixteen  diopters' 
strength  is  placed  before  the  healthy  eye,  and  the  subject 
is  requested  to  read  the  letters  on  a  distant  test-card.  If 
he  does  so,  it  must  necessarily  be  accomplished  with  the 
eye  which  has  been  declared  to  be  bad  (Harlan). 

2.  A  rule  or  a  pencil  is  successively  interposed  between 
the  sound  eye  and  printed  letters,  numbers,  or  characters 
of  differcut  sizes,  so  as  to  make  some  of  them  iuvisible  to 


Simulated  Affections  of  the  Eye.  \23 

that  eye.  If  the  patient  is  able  to  read  the  types  correctly 
he  is  using  the  aveiTecl  bad  eye,  and  the  simulation  is  at 
once  revealed  (Javal).  The  necessity  of  an  al)sohite  im- 
mobility of  the  head  of  the  patient  and  the  reading-card 
is  the  great  objection  to  this  method. 

3.  The  subject  is  placed  before  a  series  of  Snellen's 
test-types  printed  in  white,  red,  and  green  upon  a  dull, 
black  ground.  These  are  gazed  at  in  various  ways  through 
red  and  green  glasses.  The  red  characters  are  rendered 
invisible  when  they  are  looked  at  with  a  green  glass,  while 
the  green  ones  cannot  be  recognized  when  they  are  looked 
at  through  a  red  glass.  During  the  tests  the  surgeon  must 
act  as  if  he  does  not  doubt  the  assertions  of  the  patient. 
Under  the  pretext  of  assuring  himself  that  the  sound  eye 
acts  properly,  it  is  to  be  covered  with  a  red  glass,  when  the 
reading  of  the  green  letters  (necessarily  with  the  bad  eye) 
will  be  an  evident  proof  of  deception.  At  the  same  time, 
if  the  test  has  been  made  in  a  proper  way,  the  degree  of 
visual  acuitv  will  have  been  obtained. 

Before  commencing  this  test  the  physician  should  see 
that  the  letters  or  characters  on  the  cards  have  been  made 
sufficiently  plain,  and  that  their  tint  agrees  with  that  of 
the  colored  glass  which  is  to  be  employed. 

Many  modifications  of  this  procedure  have  been  pro- 
posed, among  which  are  those  by  Bravais,  Dujardin, 
Stoeber,  ISTichard,  and  ]\[inor.^-^  They  are  all  based  upon 
the  principle  that  a  red  mark  upon  a  white  ground  be- 
comes invisible  when  gazed  at  through  a  red  glass.  Hav- 
ing thus  noticed  that  red  glasses  make  letters  of  the  same 
color  invisible  when  they  are  written  on  a  white  ground, 
while,  in  addition,  black  characters  are  readily  seen  under 
such  circumstances,  Bravais^-''  and  Dujardin^^^  have  sug- 
gested a  very  simple  and  practical  method  of  replacing  the 


124         Injuries  to  tlic  Eye  in  ilirir  Mi'dico-htjal  Aspect. 

tables  of  Snellen  and  Stilling.  The  subject,  whose  good 
eye  has  been  covered  by  a  red  glass,  is  put  before  the  ordi- 
nary tables,  and  satisfies  himself,  by  shutting  the  bad  eye, 
tliat  the  glass  placed  before  the  sound  eye  does  not  modify 
vision  at  all.  If  then,  at  the  time  of  the  examination,  one 
or  more  words  are  written  upon  white  paper  in  two  colors 
(red  and  black  letters)  the  red  letters  will  be  invisible  if 
the  supposedly  bad  eye  is  in  reality  amaurotic;  while,  if  all 
of  tlie  words  are  seen  and  read,  there  is  a  direct  proof  of 
simulation. 

In  order  to  determine  the  actual  degree  of  visual 
acuity  in  such  cases  Stoeber^-''  has  had  a  portable  scale  con- 
structed. It  is  composed  of  six  squares  of  red  and  green 
glass  of  the  same  size,  behind  which  are  pasted  letters 
chosen  from  the  decimal  scale  of  Monoyer.  These  glass 
squares  are  arranged  in  alternate  threes  in  two  horizontal 
rows,  and  are  fastened  upon  two  pieces  of  cardboard  that 
are  fitted  to  one  another  by  a  hinge.  The  contrivance  is 
small  in  size  and  is  of  moderate  cost.  If  in  front  of  this 
apparatus  a  frame  (the  left  glass  in  which  is  red  and  the 
right  one  green)  should  be  placed  before  the  patient's  eyes, 
it  will  at  once  become  evident  that  the  reading  of  the  letters 
on  the  red  squares  will  be  impossible  if  the  right  eye  is 
really  amaurotic. 

4.  The  procedures  in  tliis  sei'ics  of  tests  is  acconi- 
])lished  l)y  ])risms.  Tlie  plans  ai'c  both  cheap  and  valuable 
in  the  recognition  of  simnlatiou,  in  wliicli  citbcr  a  decrease 
in  central  vision  or  an  eccentric  shiinking  of  tlic  visual 
field  is  complained  of.  In  regard  to  simulation  ol'  con- 
traction of  the  fields  of  vision,  Schmidt-Kiniplcr'-"  says: 
"While  the  test-object  is  situated  on  the  limit  (jf  the  line 
of  demarkation  of  the  visual  field  of  the  one  eye,  it  may 
still  be  seen  l)y  tlu'  patient's  other  eye  through  a  ])roperly 


Si  III  Ilia  ted  Affniidiis  <if  I  he  /•-'//'".  \2o 

firraiiiit'iT  and  graded  pii.-iii.  Jf  the  test-ohjrct  is  si'eii  hy 
liotli  ryes,  and  if  tliore  is  siniidatioii,  tlio  ])atic'iit  will  state 
that  he  sees  two  ()!)jeets.  the  true  owv  and  its  iridcsceid 
(h)i!hle.  thus  piiix  iuu'  the  sininlat  imi  of  any  cdniiilaincd-nr 
nionceulai-  hiindness."" 

The  author  will  dwell  iiarticnlarly  upon  a  nioditication 
of  the  tests  of  Wuh  and  of  von  (Jraefe,  as  they  haxe  seemed 
to  him  the  most  practieal. 

AVelz's  plan  consists  in  placing  a  })rism  with  its  liase 
oidwaid  hefore  the  complained-of  eye.  In  order  to  seenrc 
a  single  image  the  right  eye  will  deviate  inward,  and  will 
heeome  straight  when  the  i)rism  is  removed:  two  move- 
ments that  are  ineompatihle  with  the  ahsonce  of  binocnlar 
vision. 

An  ohjective  symptom  which  is  more  or  less  useful  is 
obtained  from  a  sliglit  variation  of  the  experiment.  While 
a  prism  of  twenty  degrees'  strength  is  being  rotated  before 
the  pronouncedly-bad  eye,  the  patient  is  requested  to  read 
some  printed  matter  aloud.  If  binocular  vision  exists,  the 
reading  of  very  fine  letters  will  be  quite  difficult,  or  at  least 
there  will  l)e  a  marked  hesitation  during  the  procedure. 
(Berthold.) 

The  well-known  test  of  von  Graefe  consists  in  produc- 
ing a  binocular  diplopia  by  the  aid  of  a  prism.  In  such 
cases,  lest  the  simulater  should  obtain  some  knowdedge  of 
the  form  of  double  vision  that  is  caused  by  prisms,  it  is 
best  to  make  the  test  in  various  ways  at  several  different 
times.  "At  first,"  says  Giraud-Teulon,^^**  "the  knowledge 
of  the  possibility  of  seeing  two  images  wdth  one  eye  is  made 
to  enter  into  the  unconscious  judgment  of  the  patient  un- 
der observation." 

In  the  test  the  supposedly-bad  eye  is  covered.  A  prism 
with  its  base  either  up  or  down  is  placed  before  the  sound 


126         IiiJK'ii's  to  the  I'Jyc  in  their  Mcdicu-liya!  Aspect. 

eye.  The  patient  is  then  told  to  look  at  the  light  of  a 
candle;  this  done,  the  apex  of  the  prism  is  slowly  moved 
along  a  vertical  line  until  it  diametrically  cuts  the  pupil, 
in  which  position  it  is  to  be  kept  for  a  moment's  time.  If 
this  be  properly  done  the  patient  will  see  two  images,  one 
of  which  is  received  directly  through  the  free  half  of  the 
pupil,  while  the  other  passes  through  the  prism  and  is  pro- 
jected toward  its  apex. 

This  experiment  may  be  varied  in  difEerent  ways.  The 
suspected  eye  may  be  suddenly  uncovered  apparently  with- 
out intention,  and  the  prism  raised  or  lowered  so  as  to  cover 
the  entire  pupillary  area.  By  this  simple  procedure  the 
conditions  of  monocular  diplopia  are  made  to  give  place  to 
those  of  binocular  diplopia.  If  the  subject  under  such  cir- 
cumstances still  declares  that  he  sees  two  images  of  the 
candle,  the  fraud  becomes  manifest,  the  second  image  neces- 
sarily belonging  to  the  eye  which  is  said  to  be  affected.  For 
this  test  to  succeed,  however,  it  is  especially  necessary  that 
a  monocular  diplopia  may  be  quite  readily  produced  and 
that  the  physician  is  able  to  provoke  it  immediately  and 
without  hesitation.  In  fact,  it  is  with  great  difficulty  that 
a  monocular  diplopia  can  be  produced  by  the  edge  of  a 
prism.  The  subject  must  be  intelligent,  the  edge  of  the 
prism  mui^t  be  very  sharp,  the  prism  must  be  moved  very 
slowly  and  steadih^  close  in  front  of  the  eye,  and  the  eve 
itself  must  remain  motionless.  If  any  of  these  conditions 
fail  to  be  present,  or  even  if  the  pupil  contracts  but  slightly, 
the  double  images  will  immediately  disappear. 

While  endeavoring  to  determine  a  plan  to  overcome 
the  difficulties  in  producing  monocular  diplopia  by  the  edge 
of  a  prism,  the  author  has  found  a  very  simple  method  of 
provoking  a  monocular  di])lopia  by  the  aid  of  the  prism: 
one  tliat  is  so  definite  that  the  most  unintelligent  subject. 


Simulated  Affections  of  Ihr  Eye.  ]^27 

entering  into  such  a  test  with  the  worst  grace  possible,  is 
forced  to  see  the  two  flames.  Instead  of  bringing  the  edge 
of  the  prism  opposite  the  pupillary  opening,  the  base  of 
the  prism  is  moved  toward  the  circumference  of  the  cornea 
of  the  good  e\Q,  and  at  a  distance  of  ten  or  even  twenty 
centimeters  in  front  of  the  organ. 

The  tei:^t  with  the  birefracting  prism  of  Galezowski 
consists  in  provoking  a  monocular  diplopia  hy  means  of  the 
birefracting  kns  of  d'Argo.  The  advantage  of  this  prism 
is  that  it  cannot  be  distinguished  externally  from  an  ordi- 
nary one,  which  is  an  important  point  in  dealing  with  a 
simulater  Avho  is  familiar  with  some  of  the  preceding 
methods. 

The  various  stereoscopic  tests  constitute  merely  an- 
other series  of  applications  of  the  ordinary  prism. 

5.  Tests  with  pseudoscopic  mirrors.  These  are  in- 
tended to  make  a  subject  read  letters  or  see  characters  with 
the  eve  which  he  has  said  to  be  bad  which  he  thinks  that 
he  sees  with  the  good  eye.  In  these  tests  mirrors  are  placed 
parallel  to  one  another  or  in  such  a  way  as  to  form  re- 
entering, or  salient,  angles  between  them.  Various  con- 
trivances have  been  made  on  this  principle,  of  which  that 
of  Flees  as  modified  by  ChauveP^^  may  be  cited.  This  test 
endeavors  to  fulfill  the  following  conditions:  To  determine 
the  visual  acuity;  to  illuminate  objects  so  as  to  favor  a 
precise,  though  rapid,  perception  by  a  healthy  eye;  to  place 
test-types  at  such  a  distance  as  not  to  require  much  accom- 
modative effort;  and  to  obtain  by  the  aid  of  a  simple  mech- 
anism the  displacement  of  images,  so  that  objects  can,  at 
the  will  of  the  examiner,  be  seen  by  either  the  right  or  the 
left  eye  of  the  subject. 

An  apparatus  that  has  been  devised  by  Nachet  consists 
of  a  rectangular  box  which  is  closed  by  a  hinged  lid.    The 


128         Injuries  to  the  Kye  in  their  Medico-legal  Aspect. 

contrivance  is  divided  into  two  eqnal  parts,  which  are  held 
together  by  hooks.  The  box  is  so  constructed  that  it  is  easy 
to  open  it  and  change  its  parts  at  will.  The  posterior  wall 
of  the  box  is  formed  l)y  a  ]»late  of  glass  upon  Avhich  are 
jilaced,  at  one  centimeter's  distance  apart,  two  cardboards 
that  contain  graded  letters.  The  cardboards  may  be  re- 
placed by  tal)les  of  isolatcMl  letters  and  linos  of  given  sizes 
of  test-type. 

The  letters  are  illuminated  by  transmitted  light,  which 
may  be  either  obtained  from  ordinary  daylight  or  from  a 
good  artificial  illnminant.  'I'lie  anterior  wall  of  the  box  is 
fnrnished  with  two  projecting  lenses. 

If  the  subject  is  able  to  read  all  of  the  lines  easily,  both 
his  eyes  must  practically  have  the  same  degree  of  visual 
acuity,  this  amount  being  indicated  by  the  smallest  char- 
acters that  are  read.  If  he  can  read  but  one  table,  it  can 
l)e  varied  in  such  ways  as  to  readily  deceive  the  observer. 

Very  rarely  a  pretender  may  complain  of  a  sudden  and 
an  absolute  loss  of  vision  (double  amaurosis).  Such  an 
imposter,  however,  must  assume  the  attitude  and  gait  of  a 
blind  man:  walking  stiffly  and  hesitatingly.  His  hands 
must  be  stretched  out  before  him.  His  face  must  be  im- 
passive, and  his  expression  must  be  dull.  His  eyes  must  be 
turned  upward  and  his  eyelids  must  be  held  immovable, 
even  before  sudden  flashes  of  bright  light  or  if  harmful 
objects  are  threateningly  and  quickly  l)rought  close  to  his 
eyes. 

It  must  be  remembered,  nevertheless,  in  all  such  cases, 
that,  even  if  repeated  examinations  fail  to  reveal  anything 
abnormal,  and  if  it  is  to  the  patient's  interests  to  deceive, 
suspicion  as  to  his  honesty  must  be  persisted  in. 

The  symptoms  that  are  fnrnished  by  the  size  and  the 
shape  of  the  pupillary  openings  and  the  play  of  the  irides 


tSimuhited  Affivtinns  of  the  Eye.  \2d 

are  most  important  in  all  cases.  If  both  pupils  remain 
dilated  and  if  the  irides  are  immobile  npon  subjecting  the 
e_yes  suddenl}^  to  beams  of  bright  light,  it  may  be  presumed 
that  there  is  probable  blindness.  In  snch  cases  it  is  often 
necessary  to  endeavor  to  obtain  additional  information — 
such  as,  for  example,  the  duration  of  the  assumed  absolute- 
loss  of  vision.  If  to  such  a  question  the  answer  is  given 
that  there  has  been  blindness  for  a  long  period  of  time,  it 
is  well  to  inake  inquir}'  among  disinterested  parties  in  the 
patient's  own  neighborhood.  Moreover,  quite  definite  oph- 
thalmoscopic lesions  are  ordinarily  found  in  such  cases. 
Where  the  blindness  is  said  to  be  of  recent  date,  and  its 
appearance  has  been  asserted  to  be  sudden,  no  gross  organic 
lesion  may  be  visible.  In  these  types  sufficient  time  must 
be  allowed  to  elapse  before  any  opinion  is  given. 

Frequently  in  such  cases  both  eyes  may  be  advantage- 
ously kept  closed  by  a  compression  bandage,  and  a  strict 
watch  kept  in  order  to  discover  the  existence  of  deceit,  as 
such  a  test  will  be  only  easily  endured  by  those  who  are 
really  blind. 

As  a  rule,  it  will  bo  found  that  the  pretender  will  find 
it  more  convenient  to  tell  an  examiner  that  he  has  suffi- 
cient vision  to  enable  him  to  see  to  walk  alone  (double 
amblyopia). 

The  solution  of  the  other  questions  that  are  pnt  to 
the  medical  expert  should  be  furnished  by  an  exact  and 
thorough  knowledge  of  the  internal  and  the  external  dis- 
eases of  the  eye,  and  by  an  exhaustive  comparative  study 
of  the  oplithalmoscopic  lesions  of  tlie  various  pathological 
conditions. 

At  times,  the  questions  arise:  is  an  amaurosis  or  an 
amblyopia  exclusively  of  traumatic  origin?  is  it  the  result 
of  a  chronic  S3^stemic  process?  and  will  it  remain  stationary, 


130         Tiijiiiir.9  to  the  Eye  in  their  Medico-legal  Aspect. 

end  in  recovery,  or  terminate  in  permanent  blindness?  For 
the  better  answer  of  these  questions  a  careful  history  of 
the  case  is  important. 

Although  various  theories  in  regard  to  so-called  shock 
exist,  yet  the  whole  question  is  still  in  dispute.  It  is  cer- 
tain, liowever,  that  the  shock  which  affects  the  victims  of 
railway  accidents,  for  example,  becomes  the  starting-point, 
as  it  were,  of  certain  obscure  functional  disorders  of  a 
psychical  sensori-motor,  and  sensory  nature,  among  which 
are  various  ocular  disturbances.  With  many  diverse  mani- 
festations, there  may  be  associated  symptoms  which  indi- 
cate lesions  of  the  central  nervous  system  or  gross  impor- 
tant viscera. 

Typical  traumatic  amblyopia  or  hystero-traumatic 
amaurosis,  which  is  usually  unilateral  at  first,  is  charac- 
terized by  an  absence  of  definite  anatomical  lesions,  by  a 
diminution  of  direct  vision,  and  by  a  concentric  narrow- 
ina:  of  the  visual  fields  for  white  and  colors  with  an  inver- 
sion  of  the  sequence  of  the  color-series.  To  these  symp- 
toms may  be  added  a  whole  series  of  more  or  less  temporary 
signs,  such  as  paralysis  of  convergence,  strabismus,  accom- 
modative asthenopia,  spasm  of  the  sphincter-muscle  of  the 
iris  and  of  the  ciliary  muscle,  diplopia,  monocular  polyopia, 
astigmatism,  pupillary  inequality,  macropsia  or  micropsia, 
hemianopsia,  and  erythropsia. 

As  a  rule,  amblyopia  is  unilateral  at  first,  but  later  it 
becomes  bilateral  and  is  generally  more  pronounced  on  the 
hemianesthetic  side.  The  same  is  true  of  contraction  of  the 
visual  field,  which  is  generally  concentrically  diminished  in 
size.  Usually  there  are  variable  degrees  of  decrease  of  the 
light  and  the  color-senses,  presenting  quite  frequently  the 
phenomena  of  transference.  Only  very  rarely  is  an  increase 
in  the  visual  field  observed  in  connection  with  an  augmenta- 


Siniiihifrd  .{ffi'cfioiiN  of  the  Eye.  \';\\ 

tion  of  the  light-  and  the  color-  senses  (Frankl-Hochwart 
and  Topolanski^'"'-). 

According  to  Charcot,  concentric  contraction  of  the 
visual  field  is  not  met  with  outside  of  hysteria,  except  as 
the  result  of  e])ileptic  attacks  or  in  lesions  of  the  posterior 
segment  of  the  internal  capsule,  in  which  hemianesthesia 
is  found. 

Asthenupic  disturbances  with  spasm  and  paresis  of 
accommodation  are  quite  common  and,  as  a  rule,  are  very 
persistent;  Init  they  are  exceedingly  variable  in  intensity. 
Most  patients  of  this  class  of  cases  complain  of  migraine 
and  increased  tension  ahont  the  eyes,  with  ocular  and 
orbital  pain.  At  times,  the  most  prominent  symptoms  are 
photophobia,  dazzling,  cephalalgia,  and  double  vision.  Very 
often  there  are,  in  addition,  spasm  of  the  orbicidaris  mus- 
cles, slight  degrees  of  ptosis,  lacrymation,  corneal  and  con- 
junctival anesthesias,  and  marked  injection  of  the  conjunc- 
tival membranes. 

Almost  all  such  patients  present  general  manifesta- 
tions, such  as  hemianesthesia,  analgesia,  reflex  disturbances, 
attacks  of  palpitation,  and  fibrillary  tremor  of  the  muscles 
of  the  upper  extremities  and  the  lips.  At  times  there  are 
persistent  insomnia,  gastro-intestinal  symptoms  (Bouveret), 
perversion  of  smell  and  taste,  and  disturbances  of  speech. 

The  presence  of  this  type  of  general  symptoms  in  pa- 
tients supposed  to  be  neurotic  by  inheritance  and  who  fail 
to  evidence  any  taint  of  alcoholism  and  syphilis  greatly 
justifies  the  ph^'sician  in  making  a  diagnosis  of  hystero- 
traumatic  amblyopia  or  amaurosis  where  such  ocular  signs 
are  complained  of. 

On  the  other  hand,  the  fact  that  the  subject  has  not 
any  appreciable  lesion  of  the  eye,  that  he  has  normal 
pupillary  reflexes,  and  that,  although  he  says  he  is  amau- 


132         Injuries  to  the  Kyv  in  Ihcir  Mcdico-hyal  Aspect. 

rotic,  he  nevertheless  has  been  found  to  possess  binocular 
vision,  give  the  medical  expert  the  right  to  suppose  that 
the  case  is  one  of  conscious  or  unconscious  simulation. 

Simulation  of  concentric  contraction  of  the  visual 
field  and  of  hemianopsia  is  quite  difficult  to  determine. 
To  unveil  such  a  fraud,  it  is  necessary  to  obtain  the  rela- 
tive limits  of  the  various  visual  fields  at  varying  distances. 
In  this  experiment  tlie  suljjcet  will  often  expose  himself 
by  claiming  that  he  is  able  to  recognize  test-types,  for  in- 
stance, at  the  same  place  upon  a  perimeter  no  matter  what 
may  be  the  angular  deviation  that  is  employed.  It  is  easy, 
however,  to  control  the  results  of  such  tests  by  making  use 
of  prisms. 

The  prognosis  of  hystero-traumatic  neurosis  and  of 
the  ocular  disturbances  which  accouipany  it  is  most  un- 
certain. For  example,  minor  types  of  accident,  such  as  the 
more  penetration  of  a  chip  of  iron  into  the  corneal  mem- 
brane, which  is  removed  at  once  (case  of  Borel),  or  slight 
contusions  of  eyes  (Baquis^"'),  may  be  susceptible  of  a  sud- 
den aggravation  of  reactionary  signs  as  the  result  of  hys- 
teria which  may  apparently  render  the  patient  incapable 
of  using  the  eye  for  a  period  of  many  weeks  or  months. 

Hystero-traumatic  j^henomena  about  the  eye  are,  as 
a  rule,  particularly  obstinate,  and  often  rcsi.st  therapeutic 
efforts  for  long  periods  of  time.  Eelapses,  moreover,  are 
quite  apt  to  take  place  whenever  there  is  an  exacerbation 
of  the  nervous  disturbances.  Tlie  medical  expert  should, 
therefore,  give  his  opinion  cautiously.  In  some  cases,  how- 
ever, recovery  may  take  place  quite  suddenly,  allowing  the 
patient  to  resume  his  usual  occupations;  while,  on  the 
other  hand,  the  conditions  may  be  prolonged  for  consid- 
erable periods  of  time,  and  the  psychical  disturbances  may 
become  permanent. 


PAKT  FOUETH. 


Medico-legal  Expert  Testimony. 

Translated,  rewritten,  and  adapted  to  the  Courts  of  the   United 

States  of  America  by  Charles  Sinkler,  Esq., 

of  the   Philadelpliia   Bar. 

It  is  not  purposed  to  present  in  tliis  chapter  an  ex- 
hanstive  and  technical  treatise  on  the  subject  of  expert 
testimony,  but  rather  to  indicate  briefly  the  principles  that 
govern  opinion-evidence.  It  is  desired  to  discuss  the 
method  of  examining  medical  experts  in  the  endeavor  to 
inform  the  practitioner  as  to  the  nature  of  questions  likely 
to  be  asked  of  him  when  summoned  as  an  expert  witness. 
The  outline  is:  I.  Expert  evidence  in  general.  II.  Med- 
ico-legal experts.  III.  A  few  cases  in  which  expert  testi- 
mony relating  to  the  eye  has  been  ofl:ered.  IV.  Procedure 
in  the  examination  of  experts.  V.  Expert  testimony  in 
cases  of  malpractice.  A-^I.  Proposed  legislation  on  the  sub- 
ject. 

I.  As  to  expert  evidence  in  general.  A  principle  of 
tlie  law  of  evidence  is  stated  by  an  authority  on  the  subject 
as  follows:  ''Tlie  fact  that  any  person  is  of  opinion  that  a 
fact  in  issue  does  or  does  not  exist  is  deemed  to  bo  irrele- 
vant.'*^"'* That  is,  matters  of  opinion  are  inadmissible. 
But  the  same  writer  notes  an  exception  to  this  rule:  "Where 
there  is  a  question  as  to  any  point  of  science  or  art,  the 
opinions  upon  that  point  of  persons  specially  skilled  in  any 

(133) 


134        Injuries  to  the  Eijf  in  their  Medico-lcyal  Aspeet. 

such  matter  are  admissible.  The  words  science  or  art  are 
taken  to  include  all  subjects  on  which  a  course  of  special 
stud_y  or  experience  is  necessary  to  the  formation  of  an 
opinion.  But  opinions  of  experts  are  admissible  only  in 
relation  to  their  art,  and  not  as  to  matters  of  common 
knowledge." 

It  is  not  necessary,  in  order  to  call  an  expert,  that  the 
subject  of  his  special  knowledge  be  abstruse  or  recondite. 
Thus,  tailors,  gardeners,  blacksmiths,  and  others  of  kin- 
dred calling  have  been  allowed  to  testify  as  experts  con- 
cerning matters  within  the  scope  of  their  particular  knowl- 
edge. 

Expert  testimony  is  admissible  when  the  subject-matter 
of  inquiry  is  such  that  inexperienced  persons  are  unlikely 
to  prove  capable  of  forming  a  correct  judgment  upon  it 
without  such  assistance;  in  other  words,  when  it  so  far 
partakes  of  the  nature  of  a  science  as  to  require  a  course 
of  previous  habit  or  study  in  order  to  the  attainment  of 
a  knowledge  of  it.^^^ 

Opinion-evidence  of  expert  witnesses  may  be  offered 
by  either  party  at  any  time  in  a  cause  at  issue.  But  whether 
or  not  the  subject  is  a  proper  one  for  such  testimony, 
whether  or  not  the  witness  called  is  qualified  to  testify  as 
an  expert,  and  the  manner  of  his  examination  are  questions 
resting  within  the  discretion  of  the  court.  The  weight  to 
be  given  to  the  eA'idence,  when  admitted,  the  jury  is  to 
determine.  The  jury  are  at  liberty,  if  they  see  fit,  to  dis- 
regard the  expert  testimony  and  form  their  own  conclu- 
sions upon  the  matter  in  hand. 

IT.  ]\Iedico-legal  experts.  The  o])ini()ns  of  medical 
men  are  constantly  admitted  as  to  the  cause  of  disease  or 
death  or  the  consequences  of  wounds,  or  the  treatment  of 
sickness:   and  as  to  the  sane  or  insane  state  of  a  person's 


Medico-legal  Expert  Testimony.  135 

mind  as  collected  from  a  number  of  circumstances,  and  as 
to  other  subjects  of  professional  skill.""  But  his  special 
knowledge  must  be  established  and  his  examination  con- 
fined thereto. ^•''^ 

Who  is  a  medical  expert?  The  term  does  not  admit 
of  a  specific  definition;  but  a  few  decisions  on  the  point 
are  indicative.  In  the  first  place,  it  is  not  necessary  that 
he  be  the  graduate  of  a  particular  school."**  It  is  sufficient 
that  he  be  shown  a  practicing  physician.  Xo  definite  rule 
can  be  stated  as  to  what  amount  of  experience  or  study  is 
requisite  to  constitute  an  expert.  His  competency  is  a 
matter  that  is  to  be  decided  by  the  opinion  of  the  Judge 
sitting  in  the  particular  case.  In  some  States,  as  in  Penn- 
sylvania, no  persons  are  allow'ed  to  practice  medicine  with- 
out a  diploma  from  a  medical  school  capable  of  conferring 
the  degree  of  doctor  of  medicine.  It  would  seem  that  the 
same  provision  should  apply  to  the  competency  of  experts. 

It  is  the  better  rule  that  a  physician  is  not  competent 
to  testify  as  an  expert  concerning  matters  pertaining  to  a 
special  branch  of  his  profession  unless  he  has  devoted  him- 
self particularly  to  such  branch.  He  is  not  an  expert  in  a 
subject  of  his  profession  entirely  out  of  the  line  of  his 
usual  practice  and  study.  Thus,  in  an  action  against  a 
gas-company  for  injury  occasioned  by  escaping  gas,  a  phy- 
sician not  having  a  special  knowledge  thereof  w^as  not  per- 
mitted to  testify  as  to  the  effect  of  illuminating  gas  upon 
the  health.""  In  another  case  the  court  uttered  a  dictum 
to  the  effect  that  a  physician  who  had  devoted  himself  ex- 
clusively to  one  branch  of  his  profession  and  had  no  par- 
ticular experience  in  that  subject  concerning  which  he  was 
called  to  testify, — as  if  an  oculist  were  called  to  testify  as 
to  insanity, — he  would  not  be  competent.^*** 

As  to  what  should  form  the  basis  of  the  expert's  testi- 


136         Injuries  to  the  Eye  in  llirir  Mcdieo-Utjiil  Aspect. 

mony  iu  a  particular  case:  the  opiuiuu^  to  be  admissible, 
must  be  founded  either  on  his  own  personal  knowledge  of 
the  facts  testified  to  in  court  or  upon  an  hypothetical  ques- 
tion.^*^  His  evidence  as  to  facts  must  be  the  result  of  his 
own  examination.^*-  A  physician  may  not  give  his  opinion 
as  to  a  case  in  which  he  was  called  in  consultation  and 
where  his  knowledge  of  the  case  is  derived  solely  from  the 
discussion  wdth  his  fellow-consultant.^*''  A  physician's 
opinion  is  not  admissible  if  based  on  statements  made  to 
him  by  parties  out  of  court  and  not  under  oath."*  This 
rule  is  modified  in  instances  wherein  the  physician's  opin- 
ion is  founded  upon  statements  made  to  him  by  the  patient. 
Such  an  opinion  is  admissible.  This  is  somewhat  on  the 
principle  of  the  admissibility  of  dying  declarations  wherein 
impending  death  is  assumed  to  preclude  the  possibility  of 
falsehood.  The  theory  is  that  the  patient  recognizes  the 
importance  to  himself  of  giving  to  the  physician  all  pos- 
sible assistance  toward  forming  a  correct  diagnosis."'  The 
courts  are  suspicious,  however,  of  statements  made  1jy  pa- 
tients to  physicians  when  the  examination  is  made  for  the 
purpose  of  his  testimony,  and  have  in  some  cases  rejected 
testiuK)uy  founded  thereon. 

It  may  be  mentioned  here  that,  in  the  absence  of 
statutory  provision  to  the  contrary,  a  physician  may  be 
compelled  to  disclose  any  communication  made  to  him  in 
professional  confidence."''  Such  provision  to  the  contrary 
has  been  enacted"  iu  many  of  our  States,  including  Pennsyl- 
vania.^*^ But  even  where  such  statute  exists  a  phj^sician  may 
testify  as  to  such  communications  if  his  patient  waives  the 
right  of  suppression. 

Where  the  expert's  opinion  is  given  in  answer  to  an 
hypothetical  question,  such  question  must  be  based  upon 
facts  in  evidence.    A  general  discussion  of  a  disease  without 


Mcd'wij-kijal  E./pvit  Testlinoinj.  ^37 

any  reference  to  the  probable  effiict  thereof  oji  the  patient 
should  be  stricken  oat.  The  witness  may  not  pass  upon 
the  testimony  of  other  experts  given  at  the  hearing  nor 
draw  inferences  therefrom. 

What  matters  may  an  expert  testify  to?  In  general, 
physicians  may  state  the  nature  and  effect  of  the  disease 
a  person  is  aflflicted  with,  its  severity,  ordinary  duration, 
elfects  upon  the  general  health;  its  cause  and  remedy, 
symptoms  and  characteristics^*^;  but  not  the  mere  possible 
outbreak  of  some  new  disease  or  sutfering  having  its  cause 
in  the  original  injury.^''''  A  physician  may  testify  as  to  the 
extent  of  certain  injuries,  their  results,  permanency,  proba- 
ble recovery,  the  time  when  they  were  inflicted,  and  even  the 
direction  from  which  a  blow  was  received. ^^'^  He  may  give 
his  opinion  whether  a  blow  was  inflicted  before  or  after 
death,  the  means  whereby  a  wound  might  have  been  in- 
flicted, and  whether  it  probably  caused  death. ^^^  An  expert 
witness  may  state  his  opinion  as  to  the  cause  of  death  where 
such  opinion  is  founded  either  npon  personal  knowledge 
of  the  case  or  upon  a  statement  of  the  symptoms  as  given 
by  others. ^^- 

A  physician  may  describe  the  symptoms  which  appear 
upon  the  administering  of  any  particular  poison. ^^"  He 
may  say  whether  death  resulted  from  the  elfects  of  a  poison 
or  some  other  cause. ^^*  An  expert  has  been  permitted  to 
prove  blood-stains  to  be  human  or  otherwise.  Even  as  to 
whether  hair  is  that  of  a  human  being  or  animal  evidence 
has  been  given. 

An.exjDcrt  may  use  diagrams  and  plates  by  wa}"  of  ex- 
planation of  his  evidence. 

III.  The  following  cases  which  bear  npon  the  special 
subject  of  treatment  of  the  eye  are  appended  as  illustrating 
the  kind  of  testimonv  adduced  in  such  cases. 


138        Injuries  to  the  Eye  in  their  Medico-legal  Aspect. 

An  action  was  brought  for  assault  and  battery.  The 
physician  who  had  been  in  attendance  on  the  plaintiff  was 
asked  the  question  how  the  plaintiff's  blindness  could 
have  been  caused.  He  replied:  "By  gouging."  This  evi- 
dence was  admitted,  although  it  was  shown  that  the  witness 
was  not  a  specialist  in  diseases  of  the  eye.^'^'^  It  is  sub- 
mitted, however,  that  this  decision  is  not  to  be  taken  as 
authority  for  the  view  that  a  non-specialist  shall  be  ac- 
cejited  as  an  expert  witness  in  a  special  subject.  The  ques- 
tion was  one  relating  rather  to  general  surgery  than  to  the 
specialty.  The  better  ruling  concerning  testimony  as  to 
special  branches  of  medicine  is  fonnd  stated  above.*  In  a 
recent  case  a  modified  view  was  taken.  There  was  an  action 
for  damages  occasioned  by  negligence,  which  resulted  in  an 
injury  to  the  spinal  cord.  A  physician,  not  a  specialist  in 
diseases  of  this  particrdar  kind,  was  produced  as  a  witness 
to  testify  in  relation  thereto.  The  court  admitted  him. 
but  took  the  ground  that,  while  he  did  not  have  the  experi- 
ence acquired  by  a  specialist,  this  did  not  exclude  his  testi- 
mony entirely,  but  only  affected  the  value  of  it.^^^ 

The  following  question  to  a  medical  expert  was  held 
to  be  admissible:  "If  an  eye  were  inflamed  violently  for 
two  weeks  and  caustic  soda  had  gotten  into  it  two  months 
l)efore,  and  there  had  never  been  anything  the  matter  with 
the  eye  till  that  time,  what  was  the  probable  cause  of  the 
trouble?'"  And  the  expert  may  then  state  his  opinion  as 
to  what  was  the  origin  of  the  injury.^^^ 

In  an  action  for  negligence  causing  an  injury  to  the 
plaintiff's  eye,  necessitating  its  removal,  a  medical  expert 
may  testify  that  in  his  opinion  it  was  necessary  to  remove 


*  See  page  135. 


Medico-legal  Expert  Testimony.  139 


the  eye  to  save  the  sight  of  the  other,  which  was  endangered 
by  sympathetic  inflammation.'^^ 

An  expert  physician  was  asked  the  question  whether  a 
man  who  had  lost  the  sight  of  one  eye  would  be  as  able  to 
see  certain  events  at  a  particular  time  and  distance  as  would 
a  certain  person  having  the  sight  of  both  eyes.  The  court 
refused  the  testimony,  inasmuch  as  the  expert  had  not  made 
an  examination  of  the  eyesight  of  the  two  witnesses.' ^^ 

IV.  M.  Baudry  describes  in  detail  the  method  pursued 
by  the  French  courts  in  examining  experts.  It  is,  in  effect, 
tlie  summoning  by  the  court  at  the  instance  of  a  party,  or, 
it  may  be.  at  the  direction  of  the  presiding  judge,  of  three 
experts.  These  experts  constitute  a  commission  to  hear  the 
facts  upon  which  their  expert  opinion  is  asked  and  report 
their  conclusions  to  the  court. 

In  the  courts  of  this  country  the  process  as  to  expert 
witnesses  does  not  ditfer  from  that  used  in  the  calling  of 
other  witnesses;  that  is,  they  are  summoned  by  subpoena. 
The  subpama  is  a  mandatory  writ,  directing  the  person 
named  therein  to  appear  before  the  court  which  issues  it 
and  give  his  testimony  as  to  some  matter  therein  pending 
or  suffer  a  certain  penalty.  If  tlie  subpoena  is  ineffectual, 
an  attachment  of  the  witness's  person  may  be  enforced  to 
compel  attendance.  It  has  been  held  that  an  expert  duly 
subpoenaed  and  interrogated  as  such  can  be  punished  for 
contempt  if  he  refuses  to  testify  without  receiving  com- 
pensation other  than  the  ordinary  witness-fee.""^ 

As  already  stated,  the  competency  of  the  witness  to 
testify  as  an  expert  is  to  be  decided  by  the  presiding  judge, 
the  weight  to  be  given  his  evidence  by  the  jury.  If  deemed 
competent,  he  is  first  examined  viva  voce  by  the  party  by 
whom  he  is  summoned,  then  cross-examined  by  the  opposite 
party:   fiuany  subjected  to  the  redirect  examination  of  the 


140        Injuries  to  tlie  Eye  in  their  Medico-legal  Aspect. 

first  part}^    At  any  time  during  these  examinations  lie  may 
be  questioned  by  the  Judge. 

V.  Expert  testimony  in  suits  for  malpractice.  A  phy- 
sician is  reqiured  to  exercise  such  reasonable  care  and  skill 
as  is  ordinarily  possessed  and  exercised  by  physicians  in 
good  standing  of  the  same  system  or  school  of  practice  in 
the  locality  of  his  practice/"^  and  for  failure  in  such  re- 
spect he  is  liable  to  suit.  Whether  a  physician  has  in  a 
given  case  adopted  the  proper  treatment  is  a  question  on 
which  the  opinions  of  medical  men  of  the  same  school  may 
be  received,  and  they  may  state  whether  in  their  opinion 
the  treatment  was  or  was  not  proper  and  whether  or  not 
it  was  in  conformity  with  the  rules  and  practice  of  the 
profession."'-  The  expert  may  be  asked  whether  the  de- 
fendant gave  the  case  such  attention  as  it  demanded  "and 
whether  there  was  any  unskillful  management  on  his 
part/'^^"  and  whether  the  whole  treatment  was  proper  or 
not.^"^  But  he  may  not  testify  as  to  the  details  and  results 
of  another  similar  case  in  his  practice. ^''^ 

VI.  Proposed  legislation  on  the  subject  of  expert  evi- 
dence. Expert  testimony  is  peculiarly  liable  to  abuse  and 
misuse.  However  honest  the  witness  may  be,  he  is  uncon- 
sciously biased  toward  the  party  who  retains  him.  The 
present  practice  has  been  vigoroiisly  inveighed  against  by 
judicial  utterances,  by  polemics  from  the  mouths  and  pens 
of  our  judges  when  not  acting  in  their  official  capacity,  and 
by  many  lawyers.  Their  demand  for  reform  in  the  method 
of  calling  and  hearing  opinion-evidence  has  been  seconded 
by  the  experts  themselves,  medical  and  otherwise. 

In  a  recent  address  by  the  Honorable  Judge  Endlich, 
of  Reading,  Pa.,  before  the  Pennsylvania  Bar  Association, 
the  eminent  judge  thus  summarized  the  proposed  measures 
Inokino-  iofl-ard  a  reform  in  tliis  matter: — 


M<iHv()-h(j(il  E.rixii  'r<sHiii()ii!/.  ]^42 

1.  The  formation  of  a  stricter  definition  of  expert 
capacity. 

2.  Tlic  reasonable  limitation  of  the  nnmher  of  experts 
to  be  summoned  in  any  case. 

3.  The  designation  of  experts  by  the  conrt  npon  nomi- 
nation by  the  parties. 

4.  The  abolition  of  the  hypothetical  question. 

5.  The  snmmonino-  l)y  Ihe  trial-jndge  of  an  expert  of 
his  own  choice  to  serve  as  an  assessor  or  as  a  witness  to 
review  the  expert  testimony  already  in,  or  as  to  both. 

G.  The  payment  of  expert  witnesses  ont  of  the  pnblic 
treasnrv.  at  least  in  the  first  instance. 


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Bihlioyraphy.  ]^45 

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60.  Knapp,  Archiv  fiir  Augen-  und  Ohren-  heilkunde,  1869, 
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10 


]^46  BiUiograpliy. 

63.  Contrary  to  the  experience  of  Berlin,  Ostwalt  (Central- 
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64.  Hersing,  Klinische  Monatsbliitter  fiir  Augenheilkunde, 
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68.  "Bulletins  et  Memoires  de  la  Society  Fi-auQaise  d'Ophtal- 
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69.  Jeulin,  "These  de  Paris,"  1894. 

70.  Mengin,  Recueil  d'Ophtalmologie,  1882,  p.  9.  Knapp, 
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71.  Kostenitsch,  Archiv  fiir  Ophtbalmologie,  xxxvii,  4,  1892. 

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96.  Ilirschberg,  Deutsche  medicinische  Wochenschrift,  xiv, 
1894. 

97.  Hirschbcrg,  Archiv  fiir  Ophthalmologie,  1890,  S.  37. 

98.  Haab,  Bericht  tier  oplitalmologischen  Gesellschaft,  Heidel- 
berg, 1892.  Hurzeler,  Thesis,  Ziirich,  1893.  Haab,  Correspondenz- 
blatt  fiir  Schweizer  Aerzte,  1894. 

99.  "The  Electro-magnet  and  its  Employment  in  Ophthalmic 
Surgery." 

100.  Nesee,  Archiv  fiir  Augenheilkunde,  August,  1887. 

101.  Mellinger,  "Inaugural  Dissertation,"  Basle,  1887. 

102.  "Bulletins  et  Memoires  de  la  Societe  Frangaise  d'Ophtal- 
niologie," 1894,  p.  75. 

103.  Rene,  Gazette  des  Hopitaux,  1894,  p.  1087. 

104.  Gesner,  Aichiv  fiir  Augenheilkunde,  1888,  S.  197. 


]^48  Bihlioijraphy. 

105.  Low,  "Inaugural  Diss<^rtation."  Berlin,  1890.  Beer, 
Archiv  fur  Augenheilkunde,  1892,  S.  327. 

106.  Sympathetic  disease  has  occurred  but  once  in  thirty-two 
cases  of  penetrating  wounds  of  the  eye  that  have  been  under  the 
author's  care  in  the  last  ten  years. 

107.  Arinaignac,  "Bulletins  et  Memoii-es  de  la  Societe  Fran- 
Caise  d'Ophtalmologie,"  1891,  p.  73. 

108.  Finlay,  Archives  of  Ophthalmology,  October,  1892. 

109.  Parenteau,  "Bulletins  et  Menioires  de  la  Societc  Francaise 
d'Ophlalniologie,"  1893. 

110.  Uelorme,  "Traite  de  chirurgie  de  gueri-e,"  1S93,  ii.  p.  003. 

111.  Legues,  Archives  de  medecine  militaire,  February,  1892. 

112.  Santos-Fernandez,  Abeja  medica,  April.  1892. 

113.  Lacassagne,  "Medecine  judiciaire,"  1878,  et  "Traite  de 
medecine  legale,"  1886.    Vibert,  "Traite  de  medecine  legale,"  1886. 

114.  "Transactions  of  the  American  Ophthalmological  So- 
ciety," 1892. 

11.5.  Thelmier,  "These  de  Paris,"  1800. 

116.  D'Ormay,  Revue  de  medecine  navale,  1864.  Bartlielemy, 
Archives  de  Medecine  navale,  iii,  p.  509. 

117.  Von  Hippel,  Archiv  fiir  Ophthaluiologie,  1887. 

118.  Rivers,  Archives  of  O])ht,halniology,  1894. 

119.  Taufflier,  "Examen  medico-legal  des  maladies  simulees, 
dissimulees,  et  imputees."  Strassburg,  183.1.  Ollivicr.  Aunales 
d'llygiene  publique,  xxv,  1841,  p.  100.  Guerineau,  '"Du  diagnostic 
differiental  des  amauroses  vraie  et  simulee,  devant  les  conseils  de 
revision,"  1861.  Boisseau,  "Des  maladies  simulees  et  des  moyens  de 
les  reconnaitre,"  1870,  p.  250.  Barthelemy,  "Lemons  cliniques." 
1880.  Bcnoit,  "These  de  Nancy,"  1881.  Laugier,  "Dictionnaire  de 
medecine  et  de  chirurgie  pratiques,"  1882.  Derblicli,  "Dos  maladies 
simulees  dans  I'armee  et  des  moyens  de  les  reconnaitre."  Paris, 
1883.  Zul)er,  "Maladies  simulees  dans  rarmee  moderne,"  1883. 
Gentilhomme,  "These  de  Paris,"   1884. 

120.  Baudry,  "Simulation  d«  rAiiiaurose  et  TAmblydpie  et  des 
principaux  moyens  de  la  devoiler,"  1889. 

121.  Niedeu,  "Ueber  die  Sinuilation  von  Augonleiden  und  die 
Mittelihrer  iMitdeckung,"  1893. 

122.  Fuchs,  Archiv  fiir  Ophthalmologie,  xxxvii,  1892,  S.-  1. 
Courtey,  "Tlu''se  de  Paris,"  1894. 

123.  Bosc,  "These  dc  Moiilpellier."  1890-91. 


BiMioyraphij.  \^\) 

124.  American  Journal  of  llie  Medical  Sciences,  October,  1873. 

125.  Archives  of  Oplilhaliiiolouy,  xxii,  4,  p.  44. 

12(5.  "r>ulletins  et  ]\lcmuires  de  la  Socieie  Francaise  d'Ophtal- 
niologie,"   1881,  j).  1(50. 

127.  Journal  des  Sciences  Medicales  de   Lille,   18S;>. 

128.  Archives  d'Ophtalniologie,  188.",. 

12i).  Deutsches  niedicinische  M'ochensciiritL,  18U2,  24,  S.  .")(il. 

l.'JO.  "La  vision  et  ses  anomalies,"  1881,  j).  912. 

131.  Archives  de  medecine  et  de  ]iliariiia(ie  niililaires,   188.'). 

132.  Beitrage  fiir  Angenheilkniule,  Ajiril,  18'.)3. 

133.  Annali  di  Otlalniolugia,  18<)3,  xxii,  1. 

134.  Stephen,  on  "Evidence,"  Art.  48. 

135.  Smith's  note  to  Carter  vs.  Boehm,  1  S.  L.  C.  280. 
13<).  Taylor,  on  "Evidence,"  Sec.  1417. 

137.  (Jreenleaf,  on  "Evidence,"  Sec.  440. 

138.  C'orsi  vs.  INlaretzel,  4.     K.  1).  Smith.  1.     Lisiugston's  case, 
14  Crat.  5!)2.     New  Orleans  County  vs.  Alhritton,  38  Miss.  242. 

13!).  Benson  r.s.  Gas  Company,  G  Allen.  14!). 

140.  Fairchild  vs.  Bascomb,  35  Vt.  410. 

141.  Bell,  on  "Expert  Testimony." 

142.  Bailway  Company  vs.  Huntley,  38  INIich.  537. 

143.  Railway  Company  vs.  Shires,  108  111.  G17.  Heald  vs. 
Thing,  45  Me.  392.    Hunt  vs.  State,  9  Texas  Court  of  Appeals,  IGG. 

144.  Lewis,  on  "Expert  Testimony." 

145.  Greenleaf,  on  "Evidence,"  p.  114.  Yeatman  vs.  Hart,  25 
Tenn.  375. 

14G.  Stephen,  on  "Evidence,"  Sec.  117. 

147.  P.  L.,  1895,  p.  195. 

148.  Wharton,  on  "Evidence,"  See.  441.  Rogers,  on  "Expert 
Testimony." 

149.  Young  vs.  Johnson,  123  X.  Y.  Court  of  Appeals,  22G. 
Griswold  vs.  Railway,  115  N.  Y.  Gl. 

150.  Curry  vs.  State,  5  Neb.  512.  Williams  vs.  State,  G4  Md. 
384.  Lindsay  vs.  People,  G3  N.  Y.  143.  Hopt  vs.  Utah,  120  U.  S. 
430.     Ebos  vs.  State,  54  Ark.  520. 

151.  Rogers,  on  "Expert  Testimony." 

152.  Boyle  vs.  State,  61  Wis.  440.  Greenleaf,  on  "Evidence," 
See.  440. 

153.  State  r.«.  Terrill,  1  Rich.  (S.  C.)  321.  Polk  vs.  State,  36 
Ark.  117. 


150  Bibliography. 

154.  Mitchell  vs.  State,  58  Ala.  418. 

155.  Gastner  vs.  Sliker,  33  N.  J.  L.  95. 

156.  Cooper  vs.  Eailway,  56  N.  W.  42. 

157.  Flaherty  vs.  Powers,  167  Mass.  61. 

158.  Reed  vs.  City,  85  Wis.  182. 

159.  People  vs.  Marseiler,  70  Cal.  98. 

160.  Dixon  vs.  People,  168  111.  179. 

161.  Bowman  vs.  Woods,  1  Green  (Iowa)  441.  Patten  vs. 
Wiggin,  51  Me.  595. 

162.  Wright  vs.  Hardy,  22  Wis.  348.  Homer  vs.  Koch,  84  111. 
408.  Mertz  vs.  Detweiler,  8  W.  &  S.,  376.  Heath  vs.  Gleson,  3  Ore- 
gon 67.    Roberts  vs.  Johnson,  58  N.  Y.  613. 

163.  Olmsted  vs.  Zere,  100  Pa.  127. 

164.  Mayo  vs.  Wright,  63  Mich.  32. 

165.  Olmsted  vs.  Zere  (siip7-(i). 


INDEX. 


Abscess  ill  vitreous  chamber,  89. 
Acids  thrown  into  the  eye,  ef- 
fects of,  16. 
Amaurosis  and  amblyopia, 
feigned,  objective  meth- 
ods for  detecting,  119. 
feigned,     subjective    methods 

of  detecting,  122. 
hystero-trauniatic,    symptoms 

of,  130. 
unilateral,  feigned,  118. 

Amblyopia,  feigned,  118. 

objective  methods  of  detect- 
ing, 120. 
following  injuries  to  the  head, 

69. 
persistent,  due  to  rupture  of 

choroid,  67. 
traumatic,  symptoms  of,  130. 

Anterior  chamber  and  the  iris, 
foreign  bodies  in,  59. 
prognosis  of  cases  of,  59. 

Atrophic   and   pigmented   areas 
following  interstitial 
hemorrhage     into     cho- 
roid, 64. 
Atrophy,  bulbar,   due   to   pene- 
trating wounds  of  the 
sclera,  52. 
following  rupture  of  the  eye, 
103. 
Atrophy  of  the  eye  caused  by 
foreign    bodies    in    the 
anterior    chamber    and 
the  iris,  59. 
eyeball  due  to   burns   of  the 
cornea,  39. 
following   wounds   in   vitre- 
ous humor,  89. 
from  iridochoriocyclitis,  62. 


Blindness  caused  by  detonation, 
106. 
caused  by  gunpowder,  107. 
due  to  detachment  of  the  ret- 
ina, 76. 
penetrating   wounds   of    the 
sclera,  48,  51. 
following  luxation  and  avul- 
sion of  the  eyeball,  104. 
following   wounds   in  vitreous 

humor,   89. 
from  contused  wounds  of  the 
eyebrows,  4. 
lesions  producing,  5. 
detachment  of  vitreous  humor 
and   retina    by   hemor- 
rhage, 65. 
Blood-vessels  of  the  orbit,  lacer- 
ation of  the,  24. 
Burns,    deep,    of    the    eye    by 
quicklime  or  acids,  re- 
sults of,  17. 
of  the  cornea,  39. 

and  conjunctiva,  determina- 
tion of  the  caustic  w  hich 
has  caused,  113. 
deep  forms  of,  40. 
superficial  forms  of,  40. 
of  the  conjunctiva,  16. 
by  alcohol-flames,  18. 
Bun^  of  the  eye  by  mortar,  16. 
of  the  eyebrow,  8. 
of  the  eyelids,  13. 
results    of,    13. 
superficial,  of  the   ocular  en- 
velopes produced  by  ex- 
plosions, 109. 


Cataract,  distinction  between 
traumatic  and  other 
forms  of,  117. 


(151) 


152 


Index. 


Cataract  due  to  foreign  body  in 
crystalline  lens,  80". 

the     deflagration     of    gun- 
powder, 107. 
traumatic,  79. 

causes  of,  79. 

complications  of,  SU,  82. 

consequences  of  complica- 
tions of,  83. 

due  to  prolonged  operative 
]irocedures,  00. 

etiological  diagnosis  of,  ]](i. 

produced  l)y  gunpowder,  107. 

p  r  o  d  u  c  e  d  liy  penetrating 
wound  of  the  cornea, 
47. 

Cerebral  disturbance  complicat- 
ing luxatiou  and  avul- 
sion of  the  eyeball,  104. 
Cheniosis      complicating      trau- 
matit;  cataract,  S2. 
traumatic,   14. 
Choroid,    cicatrix    of,    following 
rupture,  66. 
detacliment    of.    following 
■wounds  in  vitreous  hu- 
mor, 89. 
hemorrliagic    detachment    of, 

04. 
interstitial  hemorrhage  of,  (i;>. 
laceiation    of,    accompanying 

injuries  of  the  iris,  57. 
rupture  of  the,  05. 

followed  by  amblyopia,  07. 

scotomata  in,  67. 
prognosis  of,  GO. 
traumatic  hemorrhages  in,  63. 
Choroidal     ruptures,     prognosis 
of,  00. 

Cicatrices  following  isolated 
ruptures  of  the  retina, 
71. 

Cicatrix    following    rupture    of 
choroid,  06. 
wounds  of  the  retina,  68. 

Ciliary  body,  foreign  bodies  in 
the,  01. 


Ciliary  body,  wounds  of  the,  61. 
due  to  rupture  of  the  scle- 
rotic,   55. 

Colobomata,  57. 

Color-perception,  subnormal,  fol- 
lowing  injuries   to  the 
head,  09. 
Complex  lesions   of  the  eyeball 
produced     by    fire-arm 
wounds,  105. 
Compression  of  the  optic  nerve 
in  contused  W(junds  of 
tlie  eyebrows,  5. 
Conjunctiva,  burns  of,  14. 
by  alcohol-flames,  IS. 
by  metals,  18. 
by  steam,  18. 

complications  of,   18. 
ecchymosis  of,  14. 
foreign  bodies  in  the,  14. 
foreign  bodies  long  remaining 

in,  15. 
prognosis   of   injuries    due    to 

foreign  bodies,  15. 
traumatic    extravasations 
into,  14. 
diagnosis  of,  14. 
A\ounds  of  the,  15. 

Conjunctivitis,  simulated,  113. 
traumatic    and     spontaneous, 
ditlerential  diagnosis 
of,  114. 

Contraction  of  tlie  visual  held, 

simulation  of,  L'Jli. 
due  to  foreign  bodies  in  the 

vitreous  humor,  91. 
Control  test  in   examining  eye 

for   feigned   amaurosis, 

119. 

Contusion,   luxation,   and   avul- 
sion of  the  eyeball,  97. 
of  the  base  of  tlie  orbit,  20. 

prognosis  of,  20. 
of  the  eyebrow,  epileptic  at- 
tacks in,  7. 

Contusions  of  the  cornea,  33. 
of  the  evelids,  10. 


Index. 


153 


Cornea,  burns  of  tlic,  39. 

prognosis  of,  30. 

contusions  of  the,  30. 

results  of,  36. 
foreign  bodies  in  the.  37. 

complications  of,  38. 
partial    destruction    of,    com- 
plicating injury  to  the 
anterior    chamber    and 
the  iris.,  5!>. 
penetrating  wounds  of  the,  35. 
complications    and    results 
of,  35. 
pricking  of,  by  metallic  pen,  34. 

scratches  of,  by  finger-nail,  34. 

iraiunatic  lesions  of  the,  33. 

opacities  of,  34. 
w  (Hinds  and  contusions  of  tlie, 
33. 

wcninds  of,  by  stunc,  35. 

the  complications  of,  34. 

prognosis  of,  35. 

-rare  complications  of,  3<>. 

temporary  results 'of,  33. 

Corneal  fistula  following  Avound, 
30. 
wounds,     influence     of     dis- 
eases   of    the    conjunc- 
tiva upon,  38. 

Crystalline     lens,     degeneration 
of,      due      to      foreign 
bodies  in,  88. 
dislocation  of,  into  the  vit- 
reous humor,  79. 
displacements     of,     distinc- 
tion between  traumatic 
and  other  forms,  117. 
expulsion  of,  through  rupt- 
lu-e  of  the  sclerotic,  55. 
foreign  bodies  in  the,  85. 
diagnosis  of.  85. 
efi'ects  of,  88. 
l)rognosis  of,  88. 
incarceration  of,  by  rupture 

of  sclerotic,  55. 
luxation    and    subluxation 
of,     sympathetic     com- 
plications of,  79. 


Crystalline  lens,  luxation  of,  ac- 
companying   injury    of 
the  iris,  57. 
due     to     penetrating 
wounds    of   the   sclera, 
51. 
opacification      of,       accom- 
panying  injury    of   the 
iris,  57. 
opacification     of,     due     to 
penetrating   wounds  of 
the  sclera,  51. 
opacity   of,  due  to   nqiUue 

of  the  sclerotic,  53. 
rupture   of   the    capsule    of 

the,  .78. 
traumatic      luxations     and 
subluxations  of,  77. 
causes  of^  77. 
symptoms  of.  78. 
\  arieties  of,  77. 
varying  cA'ccts  of  different 
kinds  of  foreign  bodies 
in,  87. 
C  y  c  1  i  t  i  s ,     sympathetic,     from 

iridochoriocyclitis,  62. 
Cysts     of     the     iris     following 
wound  of  cornea,  30. 

IJeatli   following  wound  of   the 
cornea,  30. 
from  contused  wounds  of  eye- 
brow. 3. 

Dilation,  paralytic,  of  the  pupil, 
following  contusion  of 
the  eyeball,  101. 

l<>chymosis  of  conjunctiva,  14. 

Enophthalmos    and    diminished 
visual    acuity    in    con- 
tused   wounds    of    eye- 
brow, 8. 
following    contusion    of    the 

eyeball,  104. 
produced  by  fire-ann  wounds, 
105. 

Erosions  of  cornea  following 
contusion  of  eyeball, 
102. 


154 


Index. 


Erysipelas      complicating     con- 
tused   wounds    of   eye- 
brow, 3. 
Expert  evidence  in  general,  133. 
proposed  legislation  on  the 
subject  of,   140. 
Expert   testimony   in   suits   for 
malpractice,  140. 
relating  to  the  eye,  137. 
Exjjerts,    procedure    in    the    ex- 
amination of,  139. 
medico-legal,  134. 
Extravasations,  traumatic,  into 

conjimctiva,  14. 
Eye,  atrophy  of  the,  caused  by 
foreign    bodies    in    the 
anterior    chamber    and 
iris,  59. 
retina  and  choroid,  75. 
following    woimds   in  vitre- 
ous humor,  89. 
destruction     of,     by     foreign 
bodies     in     the     retina 
and  choroid,  75. 
due  to  foreign  bodies  in  the 
vitreous  humor,  93. 
loss    of,    due    to    penetrating 
wounds   of   the    sclera, 
51. 
of,   from    injury   to    ciliary 

bodies,  61. 
of,  produced  by  explosions, 
109. 
old  disease  of,  referred  to  re- 
cent accidents,  114. 
rupture  of  the,  by  violent  con- 
tusions, 103. 
simulated  or  exaggerated  af- 
fections of  the,  110. 
Eyeball,  avulsion  of  the,  103. 
contusion,  luxation,  and  avul- 
sion of  the,  97. 
contusions   of   the,   complica- 
tions following,  102. 
prognosis  of,  103. 
symptoms  of,  101. 
injtiries  of  the,  by  detonation, 
lOG. 
caused  by  fire-arms,  105. 


Eyeball,  injuries  of,  caused  by 
fire-arms,  complications 
following,  105. 
luxation  and  avulsion  of  the, 
complications  of,  103. 
prognosis  of,  104. 
luxation  of  the,  103. 
powder-burns  of,   106. 

in  relation  to  the  point  of 
explosion,  107. 
wounds  of  the,  104. 
Eyebrows,  burns  of  the,  H. 

contused  wound  of,  adherent 
cicatrix  in,  6. 
blindness  from,  4. 
complicated    bv    erysipelas, 
3. 
suppuration     of     orbital 
connective  tissue,  3. 
compression    of    the    optic 

nerve  in,  5. 
death  from,  3. 
diagnosis  of,  3. 
cnophthalmos  in,  8. 
epileptic  attacks  in,  7. 
fistida  as  a  result  of,  3. 
from    a    medico-legal    point 

of  view,  8. 
keratitis  due  to,  8. 
lesions  producing  blindness 

in,  5. 
neuroses  of,  3. 
osteitis  as  a  result  of,  3. 
prognosis  of,  3. 
retrobulbar  neuritis  in,  5. 
traumatic  hysteria  in,  9. 
treatment  of,  3. 
contusions  of,  1. 
complicated,  1. 
facial   paralysis   in,  7. 
hemiatrophy  in,  7. 
neuralgia  in,  7. 
tetanus  in,  7. 
trismus  in,  7. 
wounds  of  the  supraorbital 

nerve  in,  7. 
wounds  of,  by  projectiles,  8. 
Eyelids,  burns  of  the,  10,  13. 
results  of,  13. 


Index. 


155 


Eyelids,  contused  wounds  of,  12. 

results  of,   12. 
contusions  of  the,  10. 

differential  diagnosis  of,  10. 
wounds  of  the,  10. 

by  pointed  instruments,  11. 

Fistula  as  a  result  of  contused 
Avounds  of  eyebrow,  3. 
Foreign   bodies   in  the  anterior 
chamber  and  iris,  59. 
prognosis  of,  3. 
conjunctiva,  14. 
crj^stalline  lens  complicating 

traumatic  cataract,  83. 
interior  of  the  eye  due  to 
penetrating  wounds  of 
the  sclera,  51. 
orbit  complicating  luxation 
and     avulsion     of    the 
eyeball,  104.  ' 
penetrating  the  orbit,  25. 
complications  of,  26. 
Fractures  of  the  orbit  produced 
by     fire-arm     wounds, 
105. 
of  orbital  wall,  21. 

complicating   luxation    and 

avulsion,  104. 
direct,  22. 

effects  of,  22. 
effects  of,  upon  vision,  21. 
indirect,  21. 

Glaucoma,  chronic,  due  to  sub- 
luxation   of    the    crystalline 

lens,  78. 
complicating  traumatic  cata- 
ract, 83. 
due  to  burns  of  the  cornea, 
40. 
due  to  dislocation  of  crystal- 
line lens,  79. 
from   wounds   of   the   cornea, 
35. 

Hematoma,  orbital,  significance 
of,  20. 


Hemianopsia,      simulation      of, 

132. 
Hemorrhages  into  the  anterior 
chamber,    distinction 
between  traumatic  and 
constitutional,  110. 
choroid,  distinction  between 
traumatic  and  constitu- 
tional, 116. 
retina,  distinction   between 
traumatic  and  constitu- 
tional, 116. 
vitreous    chamber,    progno- 
sis of,  64. 
humor,      distinction      be- 
tween   traumatic    and 
constitutional,  116. 
in      the      retina,      traumatic, 

symptoms  of,  70. 
intraocular,  due   to   penetrat- 
ing    wounds      of     the 
sclera,  51. 
subconjunctival,  produced  by 

explosions,  109. 
subretinal,  prognosis  of,  04. 
Hemorrhagic    effusion    beneath 
the  conjunctiva  follow- 
ing   contusion    of    the 
eyeball,  102. 
into   the   anterior   chamber 
following  contusion   of 
the  eyeball,  102. 
into  the  vitreous  humor  fol- 
lowing contusion  of  the 
eyeball,  102. 

Hernia  of  the  iris  and  choroid 
following  rupture  of 
the  sclerotic,  52. 

Hyalitis  due  to  foreign  bodies 
in  the  vitreous  humor, 
93. 

plastic,  following  wounds,  89. 

suppurative,  89. 

Hyphemia,  accompanying  fis- 
sure or  laceration  of 
the  iris,  57. 

Hysteria,  traumatic,  in  contused 
wounds  of  eyebrow,  9. 


156 


Index. 


Hystero-tiaumatic  neuroses  aud 
a»ssociatecT  ocular  dis- 
turbauces,  prognosis  of, 
132. 


lallamniatioii    and    suppuration 
of  cornea  following  con- 
tusions of  eyeball,   102. 
Injuries    tu    the    nerves    of    the 
orbit,  24. 
optic  nerve,  25. 
results  ofj  2.'>. 
other  parts  of  ihe  eye  coui- 
])licating  traumatic  cat- 
aract, 83. 

Iridectomy,  improvement  of 
vision  by,  in  foreign 
bodies  in  the  anterior 
chamber  and  iris,  59. 

Iridoclioriocyclitis  due  to  foi- 
eigu  Ijodies  in  anterior 
or  posterior  chamber, 
SS. 
from  A\ounds  of  sclero-corneal 
margin,  02. 

Iridoclioroiditis,  diathetic,  sim- 
ulating traumatic,  115. 

due  to  penetrating  wouiuls  of 
the  sclera,  47,  52. 

from    wounds    of   the    cornea, 
35. 

suppurative,  due  to  injury  of 
the  ciliary  body,  61. 
Iridocyclitis,  chronic,  from  dis- 
location of  the  crystal- 
line lens,  79. 

due    tu    rujjture    of    the    scle- 
rotic, 55. 

folh)\ving  iridodialysis,  57. 

following  wounds  of  the  eye- 
ball, 104. 

Iridodialysis,  56. 

Irideremia,  50. 

Iridoplegia  following  contusion 
of  the  eyeball,  101. 


Iris,  detachment  of,  due  to  trau- 
matism, 5(). 
fissures  of  the,  congenital,  57. 

due  to  traumatism,  57. 
incarceratit)u  of,  due  (o  |)eiie- 
trating   wduiids   of  (lie 
selera,  51. 
injuries  to  the,  !>>■  eoiitusioii, 

50. 
laceration  of,  due  to  Irauma- 

iisni,  57. 
relioversion   of,   due   to    trau- 
matism, 57. 
tissue,   expidsion   of,   llirough 

scleral  rujiiiirc,  50. 
wounds     of,     complicated     by 
injuries  to   the   crystal- 
line lens,  5S. 
made    by    pointed    and   cul- 
ling   instruments,    5S. 
Iritis,     complicating     tra  lunatic 
cataract.  .^2. 
due    to    foreign    body    in    an- 
terior or  posterior 
chandjer,  S8. 
the  vitreous  humor,  93. 
prolonged  o])erative  proced- 
ures, 00. 
following  iridodialysis,  57. 


Keratalgia,  traumatic,  33. 
Keratitis  due  to  foreign  bodies 

in  the  cornea,  18. 
following   infectious  pricks  of 

crystalline  lens,  8.:. 
ulcerative,  due  to  lu.xation  or 

subluxation       of       the 

crystalline   lens,  79. 
ulcerative  with  hypopyon,  due 

to  foreign  bodies  in  the 

cornea,  38. 


Lacerations  of  the  choroid  fol- 
lowing    contusions     of 
the  eyeball,  102. 
eyelids  complicating  luxaticn 
and  avulsion,  104. 


Index. 


157 


Lacerations   of  the   eyelids  due 
to    the    deflagration    of 
gunpowder,  107. 
iris    following    contusions    of 

the  eyeball,  102. 
retina  following  contusions  of 
the  eyeball,  102. 
Lacrynial    gland    and    sac,    in 
juries  to,  31. 
results  of  injuries  to,  31. 
Leneoniata  from  Avounds  of  cor- 
nea. 35. 
Leucomata  due  to  biuns  of  the 
cornea,  40. 
contusion  of  the  cornea,  37. 
foreign  bodies  in  the  cornea, 
38. 
Loss  of  eve  from  wounds  of  eye- 
ball, 104. 
of    sight     following    isolated 
ruptures  of  the  retina, 
71. 
Luxation  of  tlie  crystalline  lens 
complicating  traumatic 
cataract,  83. 
following  contusions  of  the 
eyeball,  102. 


INfalingerers,      substances      em- 
ployed by,  113. 

Meningo-encephalitis     from     in- 
juries to  vault  of  orbit, 
21. 
produced  by  fire-arm  wounds, 
105. 

Metallic  foreign  bodies  in  retina, 
effect  of,  75. 

Metamorpliopsia  due  to  retinal 
hemoi ihage,  70. 
from  traumatic  detacliment  of 
retina,  72. 

Mydriasis,  artificial,  for  pur- 
poses of  deception,  120. 
Ijaralytic,  accompanying  fis- 
sure or  laceration  of 
the  iris,  57. 
persistent,  following  contu- 
sion of  the  eyeball,  102. 


Necrosis  as  a  result  of  contused 
Avounds  of  eyebrow,  3. 
of  the  cornea   due  to   contu- 
sion, 30. 
burns,  39. 
Xeuralgia   in   contusion   of   tlie 
eyebrow,  7. 
local,    following   contusion    of 
the  eyeball,  102. 
Xeuritis,  retrobulbar,  following 
contused  wounds  of  tlie 
evebrow,  5. 


Ocular  muscles,  rupture  of,  24. 
Opacification   of  the  crystalline 
lens     following     contu- 
sions   of    the    eyeball, 
102. 
Opacities  of  the  cornea  due  to 
powder-burns,  45. 
produced  by  explosions,  100. 
Ophthalmitis  due  to  burns  of  the 
cornea,  40. 
sympathetic,    caused    by    for- 
eign bodies  in  the  an- 
terior     chamber      and 
iris.  .59. 
com])licating  injuries  caused 

))y  projectiles.  105. 
due    to    foreign    bodies    in 
llie  retina  and  choroid, 
7ti. 
in    tlie    vitreous    humor, 
93. 
due  to  injuries  of  the  ciliary 

body,  Gl. 
due  to  wounds  of  the  eve- 
ball,  105. 
Optic  nerve,  atrophy  of,  follow- 
ing   contusion    of    the 
eyeball,  GO. 
injuries  to  the,  25. 
results  of,  25. 
Orbit,  blindness  due  to  foreign 
bodies  in  the,  26. 
contusion  of  the  base  of  the, 
20. 
prognosis  of,  20. 


158 


Index. 


Orbit,  erysipelas  due  to  foreign 
bodies  in,  20. 
foreign    bodies    in,    prognosis 

of,  2G. 
foreign   bodies  penetrating   in 
the,  25. 
complications  of,  26. 
injuries  to  the  nerves  of.  24. 
soft  parts  of,  23. 
vault  of,  20. 
meningo-encephali  tis 
from,  21. 
laceration  of  the  blood-vessels 

of  the,  24. 
meningo-eneephalitis    due    to 

foreign  bodies  in,  2G. 
paralysis    of    ocular    muscles 
produced  by  traumatism 
of  the,  22. 
phlegmon  due  to  foreign  bodies 

in,  26. 
strabismus   and  diplopia   due 
to  foreign  liodies  in,  2(). 
tetanus  due  to   foreign  bodies 

in,  26. 
thrombophlebitis,  due  to  for- 
eign bodies  in,  26. 
traumatism  of,  19. 
Orbital  edge,  traumatism  of  the, 
20. 
diagnosis  of,  20. 
symptoms  of,  20. 
Orbital   hematoma,   significance 
of,  20. 
Avail,  fractures  of,  21. 
direct,  22. 

effects  of,  22. 
effects  of,  upon  vision,  21. 
indirect,  21. 
prognosis  of,  21. 
traumatic  lesions  of  the,  19. 
Osteitis  as  a  result  of  contused 
wounds  of  eyebrow,  3. 


Palpebral  edema  complicating 
traumatic  cataract,  82. 

Pannus  due  to  burn  of  the  cor- 
nea, 41. 


Panophthalmitis      complicating 

traumatic  cataract,  82. 

due  to  injuries  of   the   ciliai-v 

body,  61. 
following  ijenetrating  wounds 
of  the  sclera,  47. 
rupture  of  the  eyel)all,  103. 
wounds  of  the  eyeball,  104. 

Paralysis,  facial,  in  contusions  of 
the  eyebrow,  7. 
of  ocular  muscles,  produced  by 
traumatism   of    the   or- 
bit, 22. 

Paresis  of  accommodation  fol- 
lowing contusion  of  tlic 
eyeball,  102. 

Perforation  of  the  cornea  due  to 
contusion,  36. 
powder-burns,  45. 
ocular     memljranes    due    to 
the  deflagration  of  gnu- 
powder,  107. 

Photojihobia  produced  by  elec- 
trical discharges,  109. 

Phthisis  bulbi  produced  by  gun- 
powder, 107.- 
following  hemorrhagic  detach- 
ment of  the  choroid,  64. 

Pigment-spots  following  retinal 
hemorrhages,  70. 

Pigmentary  infiltration  of  the 
retina  following  trau- 
matism of  the  eye,  70. 

Polycoria,  congenital,  57. 

Powder-buins  of  the  cornea,  4-"). 

Pterj'gium,  false,  differential  di- 
agnosis from  true,  115. 
traumatic,     differential     diag- 
nosis from  true,  1 15. 

Pupil,  condition  of  the,  as  an 
objective  method  for  de- 
tecting feigned  amauro- 
sis and  aml)lyopia,  119. 

Pupils,  supplementary,  57. 

Purulent  infiltration  of  the  cor- 
nea complicating  trau- 
matic cataract,  82. 


Index. 


159 


Eetina     and     choroid,     foreign 
bodies  in  the,  72. 
complications  caused  by, 

75. 
prognosis  of,  74,  70. 
atrophy  of,  due  to  hirge  effu- 
sions, 70. 
following  contusions  of   the 
eyeball,  G9. 
cicatricial  contraction  of,  fol- 
lowing hemorrhage,  65. 

detachment  of,  accompanying 
injui'ies  of  the  iris,  58. 

blindness  due  to,  76. 

by  foreign  bodies  in  the 
retina  and  choroid,  75. 

by  large  effusions,  70. 

due  to  penetrating  wounds 
of  the  sclera,  48,  51,  52. 

due  to  penetrating  wounds 
of  the  sclera,  prognosis 
of,  53. 

due  to  rupture  of  the  scle- 
rotic, 55. 

following  wounds  in  the 
vitreous  humor,  89. 

isolated  ruptures  of,  71. 
loss  of  sight  following,  71. 
prognosis  of,  71. 
symptoms  of,  71. 
laceration     of,     accompanying 
injuries  of  the  iris,  58. 
rupture  of,  follo\Wng  extra\a- 

.sations  into,  64. 
shock  of  the,  68. 

symptoms  of,  68. 
traumatic  detachment  of  the, 
diagnosis  of,  118. 
metamorphopsia  from,  72. 
modes  of  production  of,  71. 
prognosis  of,  72. 
symptoms  of,  71. 
wounds   of,  followed   by  cica- 
trix, 68. 

Eetinal    hemorrhages    followed 
by  pigment-spots,  70. 
prognosis  of,  70. 

Retinitis,  pigmentary,  70. 


Retinochoroiditis,  diathetic,  sim- 
ulating traumatic,  115. 
Rupture  of  ocular  muscles,  24. 
of  the  capsule  of  the  crystal- 
line lens,  78. 
following  contusions  of  the 
eyeball,  102. 
of  the  choroid,  66. 
of    the    eyeball    complicating 
luxation   and  avulsion, 
104. 

Ruptures,  isolated,  of  the  cho- 
roid, 65. 
retina,  71. 
of  the  zonule  of  Zinn  follow- 
ing   contusions    of    the 
eyeball,  102. 

Sclera,  burns  of  the,  47. 
prognosis  of,  47. 
result  of,  47. 
foreign  bodies  in  the,  46. 
injuries  to  the,  46. 

complications  of,  46. 
penetrating  wounds  of  the.  47, 
52. 
complications  of,  51. 
prognosis  of,  47. 
rupture  of,  accompanying  in- 
jury of  the  iris,  57. 
multiple    ruptures    of    cho- 
roid, 66. 

Sclero-corneal   margin,    penetrat- 
ing wounds  of  the,  62. 
Sclerotic,  rupture  of  the,  53. 

consequences  of,  54. 

ultimate  result  of,  55. 

Sootomata  due  to  foreign  bodies 
in  the  retina  and  cho- 
roid, 76. 
vitreous  humor,  91. 

due    to   retinal    hemorrhages, 
70. 

due  to  rupture  of  the  choroid, 
66,  67. 

due   to  hemorrhages  into  the 
vitreous  humor,  90. 


160 


Indea-. 


Section   of  musclos   of  the   eye 

produced    by     fire-iu-m 

wounds,  lO.i. 

of   llio    optic   nerve    produced 

by  ilre-arm  wounds,  10;"). 

Spasm  of  the  iris  following  con- 
tusions of  tlic  eyeball, 
101. 

Staphyloma  due  to  contusions  of 
the  cornea,  37. 

duo  to  foreign  bodies  in  the 
cornea,   .38. 

following  rupture  of  the  scle- 
rotic, 52. 

Suppuration  due  to  jienetrating 

wounds    of   the    sclera, 

52. 
general,  of  the  eyeball,  due  to 

foreign    bodies    in    the 

vitreous  humor,  02. 
of    orbital    connective    tissue 

complicating     contused 

wounds  of  eyebrow,  3. 
Sympathetic  conditions  clue   to 

])enetrating   wounds   of 

the  sclera,  52. 
Synechia   accompanying   fissure 

or  laceraticin  of  ihe  iris, 

57. 


Test  (Bravais  and  Dujardin"s) 
for  feigned  amavu'osis 
and  amblj'opia,  123. 

Galezowski's,  for  feigned 
amaiu'osis  and  ambly- 
opia, 127. 

Haidan's,  for  feigned  amauro- 
sis and  amblyopia,  122. 

Javal's,  for  feigned  amaurosis 
and  amblyopia,  122. 

Schmidt-Eimjiler's,  for  feigned 
amaurosis  and  ambly- 
opia, 124. 

Snellen's,  for  feigned  amauro- 
sis and  amblyopia,  123. 

Stoeber's,  for  feigned  amauro- 
sis and  amblyopia,  123. 


Test,  von  Graefe's,  for   feigned 
amaurosis    and    ambly- 
o])ia,  125. 
U'elz's,  for  feigned  amaurosis 
and  anil)Iyo])ia,  125. 

Tests,  stereoscopic,  for  feigned 
amaurosis  and  ambly- 
opia, 127. 

Tetanus    due    to    contused 
wounds  of  the  eyebrow, 
7. 
due  to  wounds  of  the  cornea, 
3{J. 

Traumatic  lesions  of  the  orbital 
^yalls,  19. 
produced  by  explosions.  100. 

Traiunatism  of  the  orbital  edge, 
20. 

Traumatisms  of  the  orbit,  19. 

Trismus  in  contirsions  of  the  eye- 
brows, 7. 

Vision,     defects     of.     following 
hemorrhages    into    the 
vitreous  humor,  90. 
diminution  of,  following  con- 
tusions of   the   eveball, 
102. 
disturbance    of,    by    luxation 
and  siibluxation  of  the 
crystalline   lens,   7S. 
loss  of.  due  to  retinal  hemor- 
rhage, 70. 
Visual  axes,  direction  of  the,  as 
an  objective  method  of 
detecting  feigned  amau- 
rosis    and     amblvopia, 
121. 
Vitreous    chamber,    abscess    of, 
89. 
invasion   of,    by   large   effu- 
sions, 70. 
humor,   defects   of  vision   fol- 
lowing hemorrhage  into, 
90. 
cfTects    of   metallic    foreign 

bodies  in  the,  93. 
extravasation  into,  64. 
foreign  bodies  in  the,  91. 


Index. 


161 


Vitreous  humor,  foreign   l)Oflie-; 
in  the,  diagnosis  of,  !)l. 
prognosis  of,  i)2. 
heniorrhage      into,     accom- 
panying injuries  to  tlie 
iris,  38. 
into,  jjrognosis  of,  90. 
loss  of,  due  to  penetrating 
wounds    of    tlie    sclera, 
51. 
wounds  of  thC;  89. 

Wounds iu  the  vitreous  humor,  -^M. 
Wounds  of  the  conjunctiva,   15. 
complications  of,   15. 
of  the  cornea,  33. 


NN'ounds   of   the   cornea,  tempo- 
rary results  of,  33. 
of  the  eyehall,  10-4. 

of   the  eyebrows  produced   by 
projectiles,  8. 

of  the  eyelids.  10. 

by  pointed  instruments,  11. 
by  the  dellagration  fif  gun- 
powder, 107. 
contused,  12. 
results  of,   12. 

(•f  the  superciliary  region,  2. 
of  the  su|jia()rbital  nerve,  2. 
in    contusions    of    the    eye- 
brows. 7. 


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